HomeMy WebLinkAboutBLDP&G-16-007059 0\ p RcA r c •
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MAS ACHUSETTS UNIF7 APPLICATION FOR A PERMITO-PERFORM PLUMBING WORK
W( of ► I, 04 MA DA ( i"ifi PERMIT# 70
/
JOBSITE AD RESS ' 1 QV ( ► w • OWNER'S NAME t Gar "/OWNER ADDRESS v V ' ,' l /f TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT ��`
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 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 GASIOILISAND 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 _ V
ROOF DRAIN •
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
•
' WASHING MACHINE CONNECTION
WATER HEATER ALL-TYPES •
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 POUCY 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 compile ith all Perti provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Cc"- t S. R ecl I I LICENSE# `� ,�y(F SI ATURE
MP\ JP❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME C r I F- R ed C-I ( t- San ADDRESS -7 7 M c n St re e +
•
CITY OS t'e r v i l l e V STATE M A ZIP 0 Co 5 5 TEL 5O SS- H , - Co 3 Co 5
•
FAX CELL EMAIL
__ MASSACHUSET T S UNIFORM AP ATION FOR A PERMIT TO ERFORM GAS FITTING WORK
=1 CITY • 1 A ATE PERMIT# /✓L•OP-/6.'G0- '
JOBSITEADDRSSI•
I i OWNER'S NAME t O'"M
OWNER,ADDRESS I TELL: ;FAX
TYPE
R •
OCCUPANCY TYPE • OMMERCIAL1 1 EDUCATIONAL RESIDENTIAL •
PRINCLEARLY NEW:_ RENOVATION:U REPLACEMENT:' PLANS SUBMITTED: YES_ NO
APPLIANCES 1 FLOORS-I BSM 1 2 - 3 4 5 6 7 8 9 10 11 . 12 13 14
BOILER . I tl =t771.1 • =1 1 11 --- --_--`L__ 1 -L I 'L -1
BOOSTER .I `I - 'I =1 ' I _ _ II_ II_ 1� - I_ - _ 't - ;
_I
1 ,l
a_
CONVERSION BURNER • I. jI =1 It__ =1 - '1- - `I - - _II__ - ``I 'I -`-I ---'l - 'I_TTs
COOK STOVE I I I I. 31 it =I _I { _
DIRECT VENT HEATER 1--iii 3i =11 II 4l 'I II -I =1 =l 1 1, 11
DRYER_-- II 'I II RI =1 II =1 11. al =1 = Ii. :I
FIREPLACE L =L_ `i .__ l__ =1 --'�--. =�! -71 =i_. I - 1 - -1
L-- AlFRYOLATOR - - . .-iI 01 -- 'I- -- 'L- -.0 _ __II `I_ .I __-- t -{ - -
FURNACE . I Pil.__ II.r LJI_. ._._'L- I 'l- _-IJL---=:___ '- 1 —
GENERATOR i l. I SIT_ l l
GRILLE I. --- iI 'l
fl l_ 1 1:. _.�.=I -- 'l - -_ 111 ._ ;I- - - `I- ii-- d
INFRARED HEATER I_ i I {l_i. =I I 3l Ill._ 11.,__al �I (-
LABORATORY COCKS L - .1 _ ' -I a,_ ?a_ If 1 7 -i 4 I
MAKEUP AIR UNIT I al __ dI ___,1_ II rsL_ ._1.1I L .-I !I_ -! -f! II °I ;I._ _
OVEN - 11 ' ---- L-j° -I IL •L — `L-... =`L- . - . --- i
POOL HEATER .7—el - t 7 - . C ti :il- fl ___=I ...----J.1 -L- I l -
ROOM/SPACE HEATER I ._ =L _t_.__ -
ROOF TOP UNIT : _
TEST I.. L =L_—.1[_k` _ II _— yam.=;..- =L-__'1- it --
UNIT HEATER • L--- IL _'��'I-$1— _ -1 [-_ �-I I_ __
UNVENTED ROOM HEATER I_ fi 1.. L l J " '.1_11 I _ 1 _II—aL __ i R._- - ii
WATER HEATER I-i =1 IF_1� I--- I I F— I I______!I—
OTHER I • :IL__ ; I — =1 --= 71 `7 1 L- I :1--1_- _L_ =1- -'1 =.
_ =1• I_ `{I—_.II-- _ - '� �- -���� ---L—II f' ._I_ I__- I i _ii -
I —IL--- iL -i ;1 3 1— =1- ____gi---- ‘i_ -1-- -11 - L___!
- • INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4 NO ID
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
-
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY I i 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 [D
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 complia ith all Pe inept provis'•• • e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
• PLUMBER-GASFITTER NAME I L c.-,r I S R; e d e- II ' I LICENSE#l- yC6' SFG11ATURE
MP I ' MGF JP IJ JGF LPGI CORPORATION 4#l 1 PARTNERSHIP!`#j _ ' LLC J#
COMPANY NAME:L r,r l I Pi 1 e d e I I t Son I ADDRESS I -7 7 lv1 0, i n S t re e t
CITY O S t e r v 1 I t,e I STATE M A ,ZIP O 3.Cs, 5 5 (TEL 5 U 9- H a s- -S D 3 Co,5
FAX . 1 CELL( [EMAIL i
• r