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Home My WebLink AboutBLDP&G-17-005790 MASSACHUSETTS UNIFORM APPLICATION FOR PE MIT TO PERFORM PLUMBING WORK CITY ) C( C J '"'" 1. MA DATE PERMIT# 7-00 1QO JOBSITE ADDRESS 146 De a C &'\ OWNER'S NAME / (<< 14 t~ OWNER ADDRESS 77/ TEL 7 jZ 0 eiP . FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:(kr PLANS SUBMITTED: YES❑ N0,0,1 FIXTURES 1- FLOOR-4 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 MAY U 3 2 n17 SHOWER STALL J "(JIVJ OLL t: 1 Y SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATE R OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES t-- I 0 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ' OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the j 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. / nn r` PLUMBER'S NAME LICENSE# ( , Q� GG SIGNATURE MP❑ JP g P CO P C PORATION❑# PARTNERSHIP❑.# L. ❑# COMPANY NAM "\ ( r( �Q ADDRESS n // V"l!t 7�� li've/' Cv CITY 5 0 .°"C doi-11 STATEVi ZIP 0 Ul TEL t7 7 Y 6 / )Z FAX CELL EMAIL (' ) ' • tty� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES J. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -,‘„,...--4, ' r,s CITY 5, . yq rAl l MA DATE, S Z. /7 PERMIT#&-/312--/7^aO, 7(?0 JOBSITE ADDRESS ile,p je_e_crxic,2-1•4:;e7"--OWNER'S NAME Terry 644_1"- GOWNER ADDRESS TEL'Pr-2./ 2ZCe6rA.X TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:Vf PLANS SUBMITTED: YES❑ NO R APPLIANCES-I FLOORS-4 BSM 1 2 3 4 5 6 7 9 9 10 111i 12 .13 14 BOILER T ----I BOOSTER CONVERSION BURNER _____, COOK STOVE I DIRECT VENT HEATER DRYER ' i FIREPLACE I FRYOLATOR FURNACE GENERATOR _ GRILLE I INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN il POOL HEATER ROOM I SPACE HEATER taw ) ROOF TOP UNIT TEST • .. . UNIT HEATER _ IJNVENTED ROOM HEATER WATER HEATER / I I OTHER INSURANCE COVERAGE ^�! I have a current liability insurance policy or its substantial equivalent which meets the requirements of WGL.Ch.142 YES NCB ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ilk' 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. I CHECK ONE ONLY: OWNER ❑ AGENT II1 J 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. LijiPLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP❑ MGF❑ JP 54 JGF❑ LPGI ❑ CORPORATION Cl# PARTNERSHIP❑# / LLC❑#: Y " 1 COMPANY NAME J3 r SP P �j-' (T ADDRESS _U _ L1 i.e. CITY S 0 a t i`n 0 v kAN STATE V ZIP • TEL 77 C/ 7)0 ?)7 2 1 FAX CELL EMAIL Lfl7- -------------- ---------------- -------- ------------------- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT#I PLAN REVIEW NOTES