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HomeMy WebLinkAboutBLDP&G-19-005516 t^ s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK L J amPn CITY y r ritoo , ©rlr MA DATE 11/1/Lal 9 PERMIT# /l /yam 5 7 JOBSITE ADDRESS Z I rel h 6 OWNER'S NAME /'1 r Gj5,/ OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7. FLOOR—t 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 T DEDICATED GRAY WATER SYSTEM 1 I 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 7t s WATER HEATER ALL TYPES / APR c. WATER PIPING OTHER " Q�uE DING DEPAR' 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 POUCY ❑ 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. �e 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 prov' ' n of he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %///.1 / PLUMBER'S NAME (Ngy tee.) e4�y LICENSE# SIGNATUR MP JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME ' &'1 J /LJI/j'W'O rhire)6 ADDRESS 7-1-- 1 k' Lod✓ CITY e )%S STATE/97i, ZIP d 7-6 3' TEL ✓- 0 G/9 FAX CELL (5e '316/ EMAIL Li)tni y /11"P -`—. 1,-:"., .L-1, .. MA SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f"' '11 -c—�? l�`{ j t�,// / ) nip 5�// � W�, CITY /arlM,�7i)`4'�, ?�r� k4A DATE (/ L/zai9 PERMIT* I%�✓✓v, /� �6 /V� JOESITE ADDRESS Z (5, yin l r)e.J d/ OWNERS NAME Qli (9f GOWNER ADDRESS (2 l"1.0049a L1 murk TEL FAX • TYPE '/`&g A-- rt,oICbu rn n PRINT ZV OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: Ill PLANS SUBMITTED: YES❑ NO❑ APPLIA.NCES f FLOORS-� c 27 s�M t 3 � 5 6 9 _ to •I•I 12 •€3 14 1 BOILER BOOSTER I CONVERSION BURNER, _ ' I COOK STOVE —� I DIRECT VENT HEATER i 1 DRYER i FIREPLACE FRYOLATOR _ FURNACE GENERATOR. GRILLE i INFRARED HEATER i LABORATORY COCKS I ‘ MAKEUP AIR UNIT OVEN V/ I i POOL HEATER rp _it k I ROOM I SPACE HEATER 44 7 v . . o t(' 4 V ROOF TOP UNIT TEST _.. . . ... . .. - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER J OTHER t� INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIGL.Ch.142 YES "NO J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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. '1 CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT , zi‘•, 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 w'h all Pertinent pro ' ' o"the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �J/�� L..... Ib // ,, ,, PLUMBER-GASFITTER NAME t'47, I 4-1* LICENSE# // SIGNATURE MP ❑ MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑ i `IPARNERSHIP❑#r C ,, f r LLB❑#i COMPANY NAME v5Gr.,1 l)r-1 /ltAr,iel— ADDRESS - 13[ wzk.6Wr I, n' CITY 1:7'e-nn is STATE (14/9 ZIP fie" TEL 6-85-4 1* .-7yJa I FAX CELL s4$°-‘e,8--5--n,I EMAIL 0-11)4 01967 0/ eerte,-zs-A //e41-'