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HomeMy WebLinkAboutBLDP&G-19-004072 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kAll � �/ t e' CITY Y4ke-1 `�+Cu_\ MA DATE /1 PERMIT# L./✓1'��'00 7 Q?' z. VT— JOBSITE i n '4 ADDRESS I `p f esk 0104114 'r' OWNER'S NAME A4 t OWNER ADDRESS ) Mc,: �'e—C TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IN PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:[Z 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/OILISAND SYSTEM _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _ LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL _ _ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES y WATER PIPING OTHER INSURANCE COVERAGE: / I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES© 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 ❑ 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with at e ' ent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER'S NAME Spencer Hallett LICENSE#16224 MP g JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Spencer Hallett Plumbing and Heating ADDRESS 381 Old Falmouth Rd Unit 36 CITY Marstons Mills STATE MA ZIP n2848 TEL 508-428-6080 FAX 508-428-7991 CELL EMAIL spencer@hallettplumbing.com L/ t .. ter. IVASSACABSE 'E S UNIFOiRV APPI_i sATI.ON FOR A PERMIT TO i3IEREORV1 GAS FITTING WORK ..' . 7° .; CITY ; -. 0!/1 ._. MA DATE 9//9 PERMIT#1/ 4.,,.- 9-°° JOBSITE ADDRESS?- e OWNER'S NAME GOWNER ADDRESS I /Cn ems ('gout :. . :TiET. TEL` F TYPE OR - OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY s--,, NEW:r RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES ` NOS,,,;; APPLIANCES 1. FLOORS-4 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 _...�- w ...:_ INFRARED HEATER - LABORATORY COCKS .---- ..--- _�-:___ __.:=---------- ---- -- -- --_ _- --- ----- MAKEUP AIR UNIT OVEN . ._ POOL HEATER -------- i ---_;_------: - :-------- i------------- —--- ._ ._. ROOM!SPACE HEATER _____-_ _. -__._ __.___ ROOFTOP UNIT __ .- ;- __--.-- __-. __ _..___._._.__...._-_. ___- -_.--- _--__- --.__--.--_-;.- . TEST = -- — - = _ _.__._:.. _.- -._ _:.--_-- _._. UNIT HEATER .__-- -_-- -----_ • . . ._._ ._-._-- UNVENTED ROOM HEATER , WATER HEATER - .- ��:, OTHER I — ._ _ i. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1,410 - I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -V. OTHER TYPE INDEMNITY .T. 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 acc • e t e st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance al - ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _,LICENSE#'I 22. SIGNATURE PLUMBER GASFITTER NAME SQtuSC l4Itr✓ i.._ �;.` MP / MGF E3 JP : JGF'* LPGI I CORPORATION , #13s PARTNERSHIP` #` J_. LLC,�.. # .,.,_...... -- COMPANY NAME CAR_�lTe Sa4,4,,ncl dittAWADDREss 13et 6 y IM to r__r4l 1.21.v (8 ,-,_,_ - l CITY !tYiA9.-S'tbta)s MtiuS STATE Or) ZIP• S TEL Soya `4Z CPC'Ea0 1.ELL FAX L Z fi2�-? 1 1