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Home My WebLink AboutBLDP&G-18-1477 r • MASSACHUSETTS UNIFORM APPLICATION FOR A PER IT TO PERFORM PLUMBING WORK CITY �,Af_, rM O c1 -- MA DATE ( Z PERMIT# �$'`Oc2/571 JOBSITE ADDRESS •s C,4 PST— :) / �A-D OWNERS NAME (Grocht `_ /,0,1 POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL V PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:, PLANS SUBMITTED: YES❑ NO❑ FIXTURES T 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 I , LAVATORY ROOF DRAIN / , r „I SHOWER STALL 1, ly kj . 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 Z NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L 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 . E 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'S NAME LICENSE# i/60 / �A Q SIGNATURE MP ❑ JP 2- n - CORPORATION( ❑# PARTNERSHIP/ L.# LLC❑# ,A 1'O ;P COMPANY NAME � (� % cQQ j' -f- ADDRESS ( (/ i �l � L—C (,._ /' L ^-1L CITY v 0 2-1. pm V STATE ZIP 6�p 6 TEL ) ! Y 'ci(Q 2 /Z Z. FAX CELL EMAIL 547 711 er'• ,A1C_► It rQ0(aU5tM7f/C` (441t aif 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 t MASSACEIUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CET`( .l�f ` I M O✓�"tj MA DATE !L PERMIT*PIL/�lz/S'c'tG/177 JOBSITE ADDRESS C4 P 51 -r!1 /2 OWNERS NAME ( ctrc/..-Y, ILJ pSr4 r) OWNER ADDRESS TEL 6/7- 5/ Z9/FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ({z PLANS SUBMITTED: YES❑ NO❑ I APPLIANCES l 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 i POOL HEATER ROOM!SPACE HEATER ett, [ I ROOF TOP UNIT TEST _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.1142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 74 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 j 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 LICENSE 4 f 3 I SIGNATURE MP ❑ MGF EI JP ❑ JGF❑ LPGI ❑ CORPORATION❑#F Pro 1 PARTNERSHIP❑# LLC❑# COMPANY I LAME M.,CA r f ADDRESS / AY CITY (� r f" U(A "1 STATE v ZIP O 24 67 V TEL? 7 FAX CELL 77 V 6/Q yZZ 2 EMAIL 5 ``') -v' • /lam c / o for qA-g 1-sea ,# ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY INAL INSPECTION NOTEg Yes No TH15 APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT PLAN REVIEW NOTES