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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
3 =L 7CITY , ��c,��cA 1 i\ MA DATE PERMIT# PAO/'' ✓ �
.�� JOB SITE ADDRESS J' A i � OWNER'S NAME fS'e l �
OWNER ADDRESS 5 'It TEL TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:D-- PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING j
OTHER
INSURANCE COVERAGE:
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 51 OTHER TYPE OF INDEMNITY ❑ BOND ❑
• 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 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 al Pe inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
,
PLUMBER'S NAME LICENSE# 17 7.k' SIGNATURE
MP ❑ JP EI CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME P ?,N ADDRESS J Ci D oL 1L L -� •
CITY r.4/,Yl0 t,{-/ l STATE MYl ZIP 09 c< TEL .5b tif /
FAX CELL EMAIL
•
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
•
i' ��' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
:r 7JMV� # ' �4a.
,�_ y CITY h1�. DATE PERMIT
V� JOBSITE ADDRESS1.7 ) )P �e�1n 1� OWNERS NAME /'4)4) egrO(ArY
GOWNER ADDRESS S/i/K Z TEL FAX•
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[Qt,'--
PRINT
CLEARLY NEW:V RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-+ BSM 1 2 3 1 5 6 7 s 9 10 11 12 13 14
BOILER 1 ---1
BOOSTER --j
CONVERSION BURNER.
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE '
FRYOLATOR I I
FURNACE _
GENERATOR _
GRILLE I I
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT I
OVEN i
POOL HEATER 1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1 •{
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
OTHER _
_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY vf—( OTHER TYPE INDEMNITY ❑ BOND ❑ I
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i
Massachusetts General Laws,and that my signature on this permit application waives this requirement. I
CHECK ONE ONLY: OWNER ❑ AGENT ❑ I
SIGNATURE OF OWNER OR AGENT J
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 compute wit " I Pertinent provision of the
.' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i '�
I;j. .
PLUMBER-GASFITTER NAME LICENSE#;24,71 f, SIGNATURE
MP ❑ MGF❑ JP LJ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ICI q,ij j -J ADDRESS /3 9 .00L4 -f4/ b'
CITY f 9�Pin 474 STATE Al ZIP 0 (54 TEEM-- y-1) 1 1 V
FAX CELL EMAIL
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