HomeMy WebLinkAboutBLDP&G-17-005073 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
30
a�„ CITY _jf
�. r � MA DATE wpm PERMIT# /J1 �1T�`
_77 1_11 )A ) i_ Pa.
JOBSITE ADDRESS OWNER'S NAME
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL E RESIDENTIAL
PRINT
CLEARLY NEW:(1 RENOVATION:0 REPLACEMENT:i4 PLANS SUBMITTED: YES Li NO
FIXTURES I FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i L it ii, ! _1 .. .1- , i '3,_ 1; !
CROSS CONNECTION DEVICE 1,_.,��...__ .. _ ,., !,:. , '. -,,..„, . .,_ t..,. _ 1.____, . , F
DEDICATED SPECIAL WASTE SYSTEM - !! I .. I .- al. ,(_ .. ' ,� _,__„�1 .�ti,. i.�,... :if .,
DEDICATED GAS/OIL/SAND SYSTEM r •` �9
DEDICATEDDEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
. .
DISHWASHER is . ,_ :, , i ., ., :, , .
,___ . . ,
FOOD DISPOSER '
FLOOR/AREA DRAIN
.,......
SHOWER STALL ,
SERVICE/MOP SINK
TOILET £
f E
F
1111
ffi
I ! it I if 1 ai 'I
s4. We
1ff > .d 3, gk
�b .
,. - L...A
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Xi NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY XI OTHER TYPE OF INDEMNITY [J BOND ip
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 Li
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 an 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 e with all nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 1 IG T.._ .W.1„' , . u LICENSE# _Yj9a0 SIGNATURE
_
MP .JP CORPORATION..�# PARTNERSHIP #F LLC #
f COMPANY NAME (,�, Vern,.an 10�jl-i-� ADDRESS I ag VI.��C� LQi 11
int I _
CITY L ,..lfQ', STATE � ] I ZIP I l k
.. TEL ,C
FAX I 1 CELL I
' 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
40 a07$4- \
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.,„(e
.,, xi CITY U MA DA PERMIT#J��—+ii _ 7—OD5-°73
JOBSITE ADDRESS 19 PAIL 6 W -e+ OWNER'S NAME !11 uz.,
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:/41 PLANS SUBMITTED: YES❑ NOIA
APPLIANCES-1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [N OTHER TYPE 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 nd ac.. - ,the best• r• -..j
and that all plumbing work and installations performed under the permit issued for this application will be in mplianc- , ith II P-rti ent .r.fsion of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#/5qa 0 SIGNATURE 1
MP MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION❑# J9PARTNERSHIP❑# LLC❑#
COMPANY NAME� (Mil'J'V1fl1
D. tirnoY) tOhi/d I InC. ADDRESS cl Vi//oqe L /,fCITY IL). p� V STATE l�IA ZIP 09�6g TEL ��' J' /l 00
FAX CELL EMAIL
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