HomeMy WebLinkAboutBLDP&G-20-001507 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'. CITY lJP'>T / L r a c�(k-'-'( 1 MA DATEOd
t._Ff_y �h ��PERMIT# /3�I7�`o20' iy�7
JOBSITE ADDRESS ) C%c, rAj f •K / JI OWNER'S NAME / jn ii c i3 , t . < `-;
POWNER ADDRESS (S7)T _I TEL ,,1/- 7i/7 ,FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 1
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES® NO❑
FIXTURES 11 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _.iL Ii_ i_: ki--11- - v gz_� �� _- 1n__
CROSS CONNECTION DEVICE 1_ _ . L�.Tt __...i L—J+!i Y._,_v „z-!s-i _ __.._I.__..�gl,..�._Ii__z_ /I,._ _4L ".
DEDICATED SPECIAL WASTE SYSTEM 1 A . ,IL_.____fL__.�-II_ . AL___ti _ . ��I_�.�i1_-. -�! L_._ .__ __.._ �
DEDICATED GAS/OILJSAND SYSTEM I ii______{1_,_TA_- e1_- SL. ,IL____._II__ l;- r- ��L I�
DEDICATED GREASE SYSTEM _ __I -,_4 .. ___ = ._ _s.,._.,i1�.� _ -J I _Ji_..JLr
DEDICATED GRAY WATER SYSTEM _rlr 1.._._.1}{T_(_ ,_IL___JL�_ I_,, �����JLJ
DEDICATED WATER RECYCLE SYSTEM I L __.Jy I! J 71LJ L,Ji JI _ lL_ JL,r___ , _IL J
DISHWASHER I. _IL�_ __ 1' tL_..ti_IL�._ _l' tI_ eJl- L =1�
DRINKING FOUNTAIN L�.�.�lL � ;_ ,.>1!r __ _i I_......�,1I� L.--..i1�,._..,_� __ << I_jh_,.._..A1_ 1_
FOOD DISPOSER L�..,,,. i.��...y_II-���,R.v_ .>>. �1 __IL_. . _I I..F.�. L-.�... �L._ _lL I ,
FLOOR/AREA DRAIN . -,_I.�J ...---f-__ _Li-. L �__._.J1 _ L�.L_ _,__ILJL. ,J
INTERCEPTOR(INTERIOR) .�,.�I!L____IL I ,„ �JL_a,F,_I — .9 n IJ LJ --J, 11 I,
KITCHEN SINK I _+ _ - JI �f ;__. L JL -,, 4 I I 11.__=_
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LAVATORY I Df ,.__1_ iL, k._ 1 - .__J -A� L _. It I _.. .1 . _ L
ROOF DRAIN i __. 1I JI_...�._,, . 1L 1.....�.J�___._JI___�._}_ _ L I
SHOWER STALL ...1
l ...�J IL_�I ! L�,�,I .d..,�—JI � Ih ,L _��
SERVICE/MOP SINK L_Ii_..- IL... ..��L„..._ai !...��II� 1I II_...:IL__ xa �L_.� 1 ,JI_-a...
TOILET I..._ 11 ' _, '•.. If_ _ ! - I _' ._1Z L....___ !! w ..,. _J 1
URINAL >_ _._.IP II _x ='I .�-ll . l AIL...._IL._....._.IL.�_ i.---- -':____ 4
WASHING MACHINE CONNECTION L.0 ?' 1_z., _.I _ I I._ ___,:.'L. , __ i:,,:__.,II.._t_�ITr,.�,..il,._ __if_ I ..
WATER HEATER ALL TYPES I 1C___._�._.Lm.v_al�_:_,,L.__�I`e: a.'i_.... _I a l.._ L'__41_._..._,_.£I��Ji -- -IR. �..I
WATER PIPING ;! !--.7_11_.._._i_ JL _IL _ -1_1_ __I't__ I! __, L._�JIW s I..
OTHER IL IL 11_ -,.-_=J1 7 II JI _.I.I— --
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i �_ __ �_ .a�...J �1.m._._..J= II 1, Y li J
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I2 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 ❑ •
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 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 all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n
G/- ti 0 / -��_
-PLUMBER'S NAME V V L r L �..'[_J k J) C i c�P „ 9 LICENSE# I l 1 X (1 SIGNATURE •
MP JP® COORPORATION❑# - PARTNERSHIP# . JLLC❑#
COMPANY NAME , l C� ( ( (14 V I ADDRESS y /G(/�j71 4/-i ("42 1
CITY L\) �., r Al
a ,A.-{1 I STATE (,kj4 ZIP 6 2. 6 7 -3 I TEL 77 67 //9 2 M
FAX !CELL _ j EMAIL ) I�I e� _/I,M �: ,., r,�n CCU f I C ^\
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT D D
FEE: $ PERMIT#
PLAN REVIEW NOTES
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_ • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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!I s" CITY vV , CA r n'l G'vt-'G\ I MA DATE -/Y ((,� / `7 (PERMIT#glAP-0'/-�/ 7
JOBSITE ADDRESS_..7 2_ I,) C" �l 1'� � rC�` �2�L OWNER'S NAME 7 j . Ci ,,.�� 1
GOW �OWNER ADDRESS Tapir, �;- ------TFAx'----- .----I:
TYPE OR OCCUPANCY TYPE COMMERCIAL:] EDUCATIONAL J RESIDENTIAL J
PRINT
CLEARLY NEW:J RENOVATION:J REPLACEMENT:,29 PLANS SUBMITTED: YES _.1 NO
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _i I_ J 1I I 1 1 J _.___—) J—J __ 1_ J
BOOSTER 1 I 1 ___ —
1 r_____I___I ___I .... _J J I- _I—I I
CONVERSION BURNER 1__1 l I I I 11 1 ( I--I_J
COOK STOVE I I +: I
1_ _ i__I_J �-��—I ICJ
__I -
DIRECT VENT HEATER I I - i_i _J__I 1 1 I—� —1 -I
DRYER• ! 1 1 I I I I =' 1 11 I I
FIREPLACE 1 1 1 1 I 1 1 j 1 1 - I _ I 1__1 1
FRYOLATOR I III I I I __1 _____I______I _I J
__0 FURNACE I I 1 . 1_ 1 1 1 1- 1 __.__' -J___ _ I I
GENERATOR
1 qI. - I
i_ I 1 1 I I
GRILLE __i . 1 1 ___I I
�J _ _ '___J._._J ! .__J
INFRARED HEATER _-_ !_.._. I.
I1
LABORATORY COCKS _I I I __._`.._.__I I I I
MAKEUP AIR UNIT ' i_ I 1 _.I __.._I J 1 _ _I i 1 I
OVEN I _! __ !____; -___I _-_I___.I ____I _ _! ...__._I . I__J .._ I __ I
POOL HEATER ______1______I .___1 _r.J.____I_...___I _____I_..___I _I__..1 ___I J._____J__i I
ROOM/SPACE HEATER _.____1 I_ _1 1 __._! _._.._._I_�__._ _I ___' I _.__I I _..__1
ROOF TOP UNIT I , 1 t . I i .
TEST _-� _`- ? �1 `_ II__ I
UNIT HEATER I - � -- - � ° --t . _ '
.. _._ ___ __.__ _.__ 1 _ t -__1 1 i
UNVENTED ROOM HEATER __ ___1-�� ! __w1�_ __.I_.__.I ____I I__j ___I__1 i -_,__J
WATER HEATER
__1 1_---__._I ____e I I ;__-__._I I J__I 1___I
OTHER I 1 _--' I I I I I_ ____ ____ I 1____ _1 _I I____.J _J
1 I 1 I I I ;�_ _ I'____i . I I I I I RI
tor
; ill 1 I J ! ___..I I I ----_1 I
INSURANCE COVERAGE
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES jQ NO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY .J BOND I
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 I AGENT -I
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 all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1
PLUMBER-GASFITTER NAME i Lr �� , I LICENSE# Ty4B7 I SIGNATURE
MP J MGF'J JP _..I JGF i LPGI J CORPORATION I#'_ I PARTNERSHIP Li# I LLC -(#. I
COMPANY NAME.' c 1 kJ& - p (---(4-- I ADDRESS (2, (hT7 c vO j I ___ -_-_.
CITY w... :
C( /7)1 G J STATE I ZIP Li 7‘; 73 ITEL 77 c_1li 7/2
FAX I CELL', IEMAIL S n P/' c.. r , ram Q-C j / <<1 !2, I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES