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Home My WebLink AboutBLDP&G-17-001144 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • e / CITY y4.4.,a4 4✓T71" MA DATE 712 li G PERMIT#/34v /-7--00`/99 JOBSITE ADDRESS OWNER'S NAME —d S S L e Y OWNER ADDRESS C TELM—76 o- 71-74 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES E 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 N-ci 4g060 WATER HEATER ALL TYPES I WATER PIPING )II OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Er NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er 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 compliance with all P ent provision of the c Massachusetts State Plumbing Code and Chapter 142 of the General Laws. w PLUMBER'S NAME gt (-) LICENSE# LG' '}o SIGNATURE MP❑ JP CORPORATION ISO PARTNERSHIP❑.# LLC❑# COMPANY NAME gA-V[.J @ 4-4-ADDRESS (v , dk C? CITY /)itG?„i srift STATE /PA ZIP 62-C 3( TEL X— k94 -"may 1 7- FAX CELL EMAIL -i-ncr.c i-r J 7`1 7 ; CUl1 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT it PLAN REVIEW NOTES l am- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t-yh Y t C "/' -" �:=�� , CITY li1-��l�l,vr�f I��. DATE I/L f/� PERMIT�; J34/� 7 Q/&(7/ JOBSITE ADDRESS Z.e' l°I- OP OWNERS NAME OWNER ADDRESS S✓l- TEL " ' 7#-/4. TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL-2' PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: l PLANS SUBMITTED: YES ] NO❑ APPLIANCES T FLOORS-- BSM 1 2 3 4 5 6 7 s 9 10 'I'I 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 I SPACE HEATER I ROOF TOP UNIT TEST UNIT HEATER LINVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of!VIOL.Ch.142 YES ®' NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a 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 El SIGNATURE OF OWNER OR AGENT Nt 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 Pert nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 8 4 IPA II" LICENSE# 2 C. 9 7) SIGNATURE MP ❑ MGF❑ JP[N" JGF❑ LPG' ❑ CORPORATION # PARTNERSHIP❑# LLC❑# COMPANY NAME �A V LA) I i.-✓ 64f,y1, do E rt. ADDRESS fU vk- 3ij CITY a/4w scerc STATE Alta ZIP O.L f TEL SDI-19 -- 7 V 37 FAX CELL EMAIL • 4 51- - i ? Cd - CA - ----- -- -- - -- - ----------- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERIv1IT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES