HomeMy WebLinkAboutBLDP&G-18-002000 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
S,.ia CITY /C,rry.00 h t'i-" 1 MA DATE 9.,/, //7 PERMIT#tr-d/'` `c-c'fi�"CCI
JOBSITE ADDRESS 6-6 Qc_15C�,n i.7c�/ OWNER'S NAME (oberf or Leslcr', z mrj c
POWNER ADDRESS U ` TEL S06-}E- -i52C FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL,.:,
PRINT
CLEARLY NEW:C RENOVATION:® REPLACEMENT:P`! PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ' ,I
CROSS CONNECTION DEVICE __ 1
I
DEDICATED SPECIAL WASTE SYSTEM I
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEMI
II
DED CATED WATER RECYCLE SYST EMDSHWASH
I I ER I i I '�'�DRINKING FOUNTAINFOOD DISPOSERi i I i �
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) 1
KITCHEN SINK
LAVATORY -I
ROOF DRAIN I
1
SHOWER STALL I
SERVICE/MOP SINK 1
TOILET p
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1 I
OTHER 1 I
i
I
j
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 0 OTHER TYPE OF INDEMNITY 0 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 . r''e best of• y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compl'- pre•ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��_ —
PLUMBER'S NAME James Pazakis LICENSE# L15030 ...0ill ! ATURE
MP❑ JP❑ CORPORATION❑# C-3982 PARTNERSHIP❑# LLCU#
COMPANY NAME Hall Plumbing&Heating Inc. ADDRESS 447 Old Chatham Road
CITY South Dennis STATE MA ZIP 02660 TEL 508-385-9127
FAX CELL EMAIL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WO,
atil CITY / � I 9 197 -cc "6 � � 'c
JOBSITE ADDRESS 6-6 Px„.k.)rn LubAj
I OWNER'S NAME rber`+- c�.— ley4.fnele,
GOWNER ADDRESS I TEL SC6;36 -?8? I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL L_.J RESIDENTIAL
PRINT
CLEARLY NEW: , RENOVATION: _.1 REPLACEMENT: f CQ PLANS SUBMITTED: YES i NO
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I . I. 1_ I. _ _.,i__. I 1 _. 1 I _ i ! _ ,
BOOSTER 1 ! I ._ __i _ 1__ _ _1 . i ! 1 I ! i 1
CONVERSION BURNER I _. ! _ _ I _ i.. 1 I . I ___ ! I I I I !
COOK STOVE I __..I i ._ _J. .. I'-_ __I I.._ ! I ! I I I
DIRECT VENT HEATER I I . I ..... ..( I' I`. `' I ! . !
DRYER I' ! _1'_ I I' I I 1 ! I
FIREPLACE I ! I . I I_. 1 _ l I ! ! !
FRYOLATOR I ! I I I ! I ! I ! ! 1
FURNACE I . I J.. i I ± I I i ! _
GENERATOR 1 _. , I 1 ) . I. „I,.,. . ! J. 1 l'._ I 1' !
GRILLE I I I .,.f I _ I I I I ( ��.,. i,
INFRARED HEATER _ I_ I, 1 . .. .I_. .,I I ... .. . . . I . I . ... .I.,_. 1
LABORATORY COCKS 1, ! h. I . .. .,I ... ...I ...._-.I l ! I ( . I I
MAKEUP AIR UNIT I. I. I -. I I . I I. I I !, I 1
OVEN I 1 !. I _ . J . _ Ir. __ ! I 1 I .. I,
POOL HEATER I _. .! . _ l __..l- _. _I ...I ... .. . I ., I . ____I I !1 1
ROOM/SPACE HEATER 1 _ I l !.___.•I,_ _ _I . l I 1 _ I ! I
ROOF TOP UNIT I I ! . _ I1 I ! 1
! 1 L I I I
TEST I I ! _ _ 1 I'_ I . 1 ._ . ! __ 1
UNIT HEATER 1 I ! I !'_. . . 1'._ I I ._ _. I I I
UNVENTED ROOM HEATER ! I ( I 1_ I I i 1 I
WATER HEATER I 1- __..l . I I !._ . .
OTHER i I ! ! I I _1 _ _ I I __.
__1 I. ! _ j .. - . .I. I .__. _.I'._.._ ! _ I^ . .I J _..._I 1
1 I .__I ! .__._. I 1 f I 1 I ! I..
1 j !' !' . 1 I _. . _I 1'..____ ( I ! _ ! 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 2'..1 NO _._1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i. OTHER TYPE INDEMNITY ___1 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 1 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 to th of my owledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian i all nent provisio of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
v
PLUMBER-GASFITTER NAME James Pazakis I'LICENSE# 15030 SIG TURE
MP _!_I MGF JP ! JGF I LPG' 1 CORPORATION !I#'C-3982 1 PARTN RSHIP,___I#__ __ .___J LLC _I#
Chatham Road
COMPANY NAME: Hall Plumbing&Heating Inc. ADDRESS 447 Old C ___ _ _ ___________.__
CITY South Dennis . I STATE MA _I ZIP 02660 ,. •,_. ITEL 508-385.91 7
FAX CELL I EMAIL