HomeMy WebLinkAboutBLDP&G-17-005021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•� "� CITY 9 rn: MA DATE E G3/3O/I`I PERMIT#, -t)P /7'cf
pp OWNER'S NAME
JOBSITE
ADDRESS b ,(,� �I q,cc,,iA___c,..) �L(-.�.
OWNER ADDRESS S & ..,E .!,cL Fc0 TELL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 1 EDUCATIONAL Li RESIDENTIAL 2'
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:121 PLANS SUBMITTED: YES _Ti NO u!
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 GASIOILISAND 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 L.'
TOILET
WASHING MACHINE CONNECTION /t, - t
WATER HEATER ALL TYPES L
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 V 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 accur e-t e- ledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli r h all Pertinent provision of th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME _1{,4_,G act, it y/3 LICENSE# .3l S A RE
MP JP Er CORPORATION # PARTNERSHIP# LLC j#
COMPANY NAME $J Vl bI&c1.1,ejt4i /lz >ADDRESS L.4c?�_..fijc.,bbu ay_ LA)
CITY �� (la !v S STATE Ali ZIP _Q _.,_ TEL
FAX t CELL 274$4OJm EMAIL ._..,1C_+p7,,,L .!!'JJa'iA _��/hA.��_, �►'� =1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
wiromsyti=.9 CITY J 4RrvrQv� MA DATE L 14,o 1 f 1 PERMIT#/10-/7' o ).�`4 f
JOBSITE ADDRESS dcS11C,FFI b. „ , , OWNER'S NAME .MA2G;IU Ale i LL
OWNER ADDRESS , S11 e Fc ,b h _._._.. __................_.___ _. .n_.j TEIt FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL fl RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: " PLANS SUBMITTED: YES —4 NO f'
APPLIANCES Z 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/SPACE HEATER
ROOF TOP UNIT /
TEST �- I:CJ I C.b
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1,--NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ✓ 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 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.
PLUMBER-GASFITTER NAME Vip6,Lp Saa'A LICENSE#' , ; ; SIGNATURE
MP MGF L JP ✓JGF LJ LPGI ni CORPORATION®# PARTNERSHIP # LLC #t_
.
COMPANY NAME:'Si,(,1vq. PL4.16,Avt; %t ,<J.,./; ADDRESS ��SS # C Pi Ape _ __ �Qa �._..r.
CITY Wye .t S - STATE ZIP Q OJ TEL
FAX CELL.)71m36-0176 EMAIL V!Q,(>,L;nA✓1 GAO r< ^1^