HomeMy WebLinkAboutBLDP&G-19-005518 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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_ 1 MA DATE �. A 7f 'j PERMIT# Ifi /)'//' 7
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JOBSITE ADDRESS 11 r L7rp•v z �-f d OWNER'S NAME IJ2-vf. _ eta „Fs 1
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL LI RESIDENTIAL g
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CLEARLY NEW:U RENOVATION:U REPLACEMENT:LA PLANS SUBMITTED: YES fl NO(J
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _ __It—---- } _IL._ ,._II._i I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM 1__ _ I ; _._ � ,�
DEDICATED GAS/OIL/SAND SYSTEM ; A I I 1�;,' !I_ li l
DEDICATED _ I I - ,. i i
DEDICATED GRAY WATER SYSTEM ,__ _ ,IIIIMEJMNIMM 1 W.,._MAIM _ ____
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DEDICATED WATER RECYCLE SYSTEM nit
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DISHWASHER 7[1rOgitill,IT
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FOOD DISPOSER ; II _ ;i1_ _A____I---A-i---- - i-- ---- - NW I Il I -I' -- 1-- --- 1
••-/AREA DRAIN I • 1
INTERCEPTOR(INTERIOR) mum igungsig, jam mpg ingiugginsi1111111.Mg,mg
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TOILETSERVICE/MOP SINK
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URINAL ii__MIEWREIWIllrIEB1111-11711Mr."11aWIWAirilligri
WASHING MACHINE CONNECTION :rwii alimmitiummummen
WATER HEATER ALL TYPES
WATER PIPING
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES["NO I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY ® BOND LI
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 Q 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 ct--,mpumnr.7e with all n rov lion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1_ ��
PLUMBER'S NAME I P _,r ._i/_c:'.BCl O - LICENSE# ,1_I?_647)_..1_ SIGNATURE
MP JP 0 CORPORATION t#o�% PARTNERSHIP LJ# -} „ 1 LC # -
COMPANY NAME L�'-t,,mc ,,.� e._P:+_HL._ ; .,., ADDRESS L !1 r.oL 4�.. .
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CITY �. �/��n.-.:a�,,-�I, - - STATE r��� ZIP d��W.�?-_•-____- _ �� _ �.�?�`.��-�� ... - ..�..
FAX 4 of 7'i u-U 1VI CELL f 901c)3(A-374 EMAIL __ . - e .2I1:'r .b i s()M/..Gt: T._., 0�'� .__ ---__ _ _ t _-
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MASSACHUSE I I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I Town of Y:41 :Y)U IJ i I-I j MA DATE? 1161/I q PERMIT# P- / 0 'J'W
JOBSITE ADDRESS c I ! >v t? �--1_, _- OWNER'S NAME !_� r 9,ram$
GOWNER ADDRESS f TElJ - FAX1 ^,,
TYPE'OR OCCUPANCY TYPE COMMERCIAL jj EDUCATIONAL jJ RESIDENTIAL U
PRINT
CLEARLY NEW:jj RENOVATION:D REPLACEMENT:Li PLANS SUBMITTED: YES[J NO
APPLIANCES 1- FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER - ' C __-- _--- !--,. 1 f`tr r--_1
BOOS
I ER 1
CONVERSION BURNER '_. �,�rs`1 '. .._�� .�-� . �__,t�N�-�,�..� --�- 1
- }'----tea:___--F 1— 1__ _ ! -- -z �L--_-
COOK STOVE - F4 -, .°I - J __ se.—..- .----i
DIRECT.VENT HEATER i =1 L_.I _ - -- ' Ai i
DRYER — i _:� — ?
a Mil•_____. t 1
FIREPLACE _ ___ M ' _ i
FRYOLATOR V==11 ; :i -
FURNACE '
• GENERATOR _ - ;.
GRILLE _ _a .. ' ai.• .-• a E
INFRARED HEA I EX i'M'L_ `l{.T-:. •r,-- K
LABORATORY COCKS , _ _ ' _,____9 • I • * • ' • •
MAKEUP AIR UNIT �� . .1 t
OVA : _ _p V'II
POOL HEATER • g -, - _ • ,pe le Pilis = 1 n• m __
ROOM I SPACE HEA 11=K -N1 - ,i. ..' ir�a t� '
ROOF TOP UNIT _. -' -
TEST . .
UNIT HEATER •. _ I I ___-- -*1
UNVENTED ROOM HEATER L-.,-- —1,- I i
WA I tK HEA I 1 K IT- --- ., ! : G. -s _ _ t � .
OTHER I I I i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES LI NO L
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY U - BOND ill
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 0 AGENT El
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 tope best of my knowledge
and that all plumbing work and installations performed under the pernrft issued for this application will be in compliance ' � 4' provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws
PLUMBER-GASFI I I ER NAME lieu,r, f f t C r_,-)p - !LICENSE it 1 I. 6a(2: - SIGNATURE
MP a MGF D JP 0 JGF D LPGI U CORPORATION #I a j PARTNERSHIP (LLC .4L 1
COMPANY NAME.1 ,-,McBr;c)e. Plunk-1- )-zc�' nic jADDRESSI = S j
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CITY CV J. `lr,rrnnc fjm • STATE ZIP Q*673 !mil /o ?7. - 4 55E I
FAX(g)71ct-h7XS1 CE-1-160 S64-3-7: EMAILI k<Yl lip k ^^ b c co,(-As , r(,_, I
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