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HomeMy WebLinkAboutBLDP&G-20-006336 i4 P : c C -i :6--c4(\. MASSACH USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 454-`)u�h1rA; MA DATE I S=2C1 PERMIT# �7/.i2/37 t i �, JOBSITE ADDRESS Ir16(nrs I CAraI i / n OWNER'S NAME �� (6,incv$ OWNER ADDRESS .-�4/Ain Its/` "Li M,Lk.�r 49f iiW TEL 5DA 3E67U / FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT . PLANS SUBMITTED: YES❑ Nap FIXTURES T FLOOR) BSM 1 1 2 I 3 4 1 5 1 0 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM _ _ { DEDICATED GREASE SYSTEM i { DEDICATED GRAY WATER SYSTEM I if DEDICATED WATER RECYCLE SYSTEM t DISHWASHER I { I DRINKING FOUNTAIN FOOD DISPOSER I { FLOOR/AREA DRAIN { I { { INTERCEPTOR(INTERIOR) KITCHEN SINK I fi i LAVATORY 1 1 ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK { �_ TOILET URINAL WASHING MACHINE CONNECTION I { I I 1 WATER HEATER ALL TYPES 1 ► _ } WATER PIPING { { OTHER - 1.11111.1111111111111 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of fv1GL Ch,142, YES Eli NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding Ibis application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this appiicatlonvrill be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER'S NAME c kI='•'1 ; , ..cyj ` LICENSE# c 75. 3q / SIUNA3RE MPE. JP❑ CORPORATION 0.# ;C_ PARTNERSHIP❑# LLC❑# COMPANY NAME �!— N c—\rim ADDRESS / 'CS rl , .�- CITY �;i 1�1 i 5 j r..'-1 STATE /f/r ZIP J ci/r S`'I TEL FAX ((; CELL EMAIL ifj''=;l +}-;< „fill s FA- R GEL: 3ci MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK it—,—e e ,a =rill=x CITY 6n)PS-- ''SOrw►h 4 - MA DATE -!.S'-2Yx PERMIT# t,J,)/2" 7O�"00 G�?14,li JOBSITE ADDRESSII2J-0(/G I OWNER'S NAME 0 1 rif), {{ GOWNER ADDRESS SC(3 LA lc) gri A). 2lcr1/">` 61 ,1TE 3anc_ ._IFAXL, TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT:E PLANS SUBMITTED: YESE ] NOIR APPLIANCES 1 FLOORS-' 8SM 1 1 2 3 4 5 s 7 8 9 [ to 11 12 13 14 BOILER II r... _.. ._. _.._ _ �- _.. I BOOSTER + i_, s I t - I� i -f CONVERSION BURNER J± l 'fit :.._ .i__. i _ COOK STOVE .,,_ = i ___.._ I V� DIRECT VENT HEATER 1} ,_ � IA DRYER litii�Jtrn ~ ter iII$iI! iiR!51 GENERATOR GRILLE m..,,matirstrimons ... = • I LABORATORY COCKS IIIIMMISIMMIallinlilltill .MIME 1,11.> ` MAKEUP AIR UNIT M-1 yf< •++ +• iU!1.f i 1 • i M ....' , - _ .ice I, UNIT HEATER - f ' 4W� WtM I MIM UNVENTED ROOM HEATER I namapiti WATER HEATER OTHER ' ; ---., E � �-� I + ; x INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVEN BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ei OTHER TYPE INDEMNITY fl BOND rii 1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In compliance with ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ' ` iit.z/A���,�y� at ha. 'l'1 l;-i(,' � cs_,--)u `�;_ . i LICENSE . SIGNATUR MP J MGF u JP 0 JGF® LPGI© J CORPORATION f# '2JL G L PARTNERSHIP®' , I LLC n#F.- COMPANY NAME:I 1(r.5 Pit 7,..,bi i,,c 4..ct6' . ADDRESS�SS` /► t1.� 5 t' CITY _ ,S_... ' z_....r�,.. �_�,..__. ,__.�,._�._.__._J STATE rag ZIP a 3�'t _ ,TEL 1.` __i51-1 _ .....__I FAX 1.S '._c.i-/S.! CELL _________,EMAIL ..0... - 1. __..1 ----- ..It a