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MASSA HUSETTS� UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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myieLM CITY AIM t/'� 1 MA DATE PERMI ),(� ,�`y //V �flW
®. JOBSITE ADDR SS ✓1 /q
4/7 6/1
OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: PLANS SU MITTED: 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/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
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1J NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY A 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 complia ith all Perti provision f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
17.6
PLUMBER'S NAME c r t ec1 e II
LICENSE# Say SI ATURE
MP. JP❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME C c`r I F. IR zc1 C. I( ` S 1 ADDRESS "77 , r, 6. 1-- cam' 2
CITY OS ter VI11e STATE M/-1 ZIP � Co55 TEL SCs- Co3G5
FAX CELL EMAIL
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I-.70 � PGCCC I
' MASSACH SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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9s CITY r MA DATE; RP RMIT# /1 /J' '
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JOBSITE ADDR S IOWNER'S NAME 7,0 .
GOWNER ADDRESS TE FAX j
TYPE OR OCCUPANCY TYPE COMMERCIAL E UCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOQ
APPLIANCES Z FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER i� i __,__ ._ I
1
CONVERSION BURNER l I �, . 1 t f€
COOK STOVE _ _
DIRECT VENT HEATER _ 11_ I C ��.._ _�- ='
DRYER I . __.._. 1 _...__: _..�. __.,;_.. �._ _ '
r }
FIREPLACE I �.
FRYOLATOR
FURNACE
GENERATOR .r ��
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
• ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER I ,,, 1
UNVENTED ROOM HEATER i"---r--- •
WATER HEATER I
OTHER I !, i ij
i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4NO U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
L!AB!' !TY INSURANCE POLICY \ OTHER TYPE !NnEMNITY POND
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 ;J AGENT TJ
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 �ithall Pt provi • he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � �vCQ
PLUMBER-GASFITTER NAME IC_ C,r I S P,I e d e t l LICENSE#1 eZse6 S ATURE
MP la MGF U JP LI JGF El LPG'LJ CORPORATION E# I PARTNERSHIPS# LLC #
COMPANY NAME: c-2,r I I: T , deli f SO n ADDRESS -7 7 �S I"1 c,i n S_t-ire e k- 1
CITY OStcr-v1Ile 1 STATE HA :ZIP OaC955 TEL 50S- H -.._.(D3Cfl5
j FAX CELL, EMAIL
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