HomeMy WebLinkAboutBLDP&G-19-002997 lnrP: PAC c : Fo
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ii L=-_ , L.—_°'= CITY NA. i M C i i Y"t. I�O r 'i 1! MA DATE I t A iii 'b 1 PERMIT# L-OP/9-r- N9
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JOBSITE ADDRESS t 7 Plays ro u n e0 /2 n. I OWNER'S NAME 4...in ND SPr 00,e m `
P _.OWNER ADDRESS t( g TEL0 DO 1 I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:tZi PLANS SUBMITTED: YES® NoI
FIXTURES 7. FLOOR—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ______I _ ___J IL_1=1_ JL I�_I , IL _ t[ ,J1 1 - I�CROSS CONNECTION DEVICE
__ !I= i ._�t .1 . 1.__ L ��, L____.�J
DEDICATED SPECIAL WASTE SYSTEM .,f I .--IL__-A J . L__"A. I__ I -- .iT_.� I �_II 1 __I
DEDICATED GAS/OIUSAND SYSTEM L. J _ ._ 1 _) _ d e, _I ,J!_-. L___.__I I__,_ L.�. L
DEDICATED GREASE SYSTEM j - _' _-_.I L, _ ,__L___ __, L..,,J _ _ II JI.JL J
DEDICATED GRAY WATER SYSTEM MR I ? IIIIIR --- ,,._ .I .__.. ;I �_ _z I_ _,,__.,_"I. �,�i
DEDICATED WATER RECYCLE SYSTEM , I. 1,1
- 1 —J 'i .:,_1-- ._ _.I MN I ---,.J1 _ IL___I
DISHWASHER I :__ L I _ 'l ! -I. ..,_e ii _ I1TT_fJ_ JLLR i____J
DRINKING FOUNTAIN I I L -_ 3� I�, f /L.�.1 11 ,:I=
FOOD DISPOSER �.1 _ I ,�_. .1 I �,.IL _ : ..-�.�.,=_it_ 11_,I
FLOOR/AREA DRAIN _ ,. .ir ,_ ==I--- - ;h— -_ _i_II _IL _Al 1
INTERCEPTOR(INTERIOR) L -,___I,.._ _1L.J _,, _ I - I . _ 1 _ _ I _ _IL ,___,J
KITCHEN SINK ' 3 1 I _; J ._,:_ _ J_ I . J. I _-_ I
LAVATORY II.�wI 11,,____ 1— °1. A _I __It�# I
ROOF DRAIN i _ , �' _. i . _ i_st f J 'I I
SHOWER STALL IL.., s i II _�i :I,,_. _,IL _. I.=__ _ I �I II 1
SERVICE/MOP SINK - _ -.w`L... .A11 .�__!1 .�J _ 1__._I I , _ �_
TOILET 31 1 _.,._ � _.,�.�_JL ;I_- --L_k !' _ '1 _fir_ ..�_ I _
URINAL I , -1L_�.__.I I ._;I.._..,�, _ I _ ' _31,_._.I L __ LW>_ IL,�,_.. � ,
WASHING MACHINE CONNECTION II I' ` 1 .�. _.._.'L_ 3_r_�I:I 1 . . I_�,FI °�.=t_I
WATER HEATER ALL TYPES LTI:,..,_.i ' --'L. il V.,.=I. ' _.,._ I _R,. _ „
WATER PIPING i_ 3i L.__31 �,il__ ELe.___ib ,..J 1._, �.�'=1 _.J _ __.
OTHER I I = -II_ I- -=a II,___ II �T3_ _ - _ _�
M 1 1 I 1 11
i is 1 I1 11 II�_1 Ir._.m _ L..__1I_— I ._, .i.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2 NO J
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY cil OTHER TYPE OF INDEMNITY ED 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 Li AGENT Li
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. n
PLUMBER'S NAME , +^ .L _e_, _ LICENSE# I i 0-f_� SIGNAT
1• URE
MP Li JP I Pr 0 !` ' CORPORATION I.___I# _ _'PARTNERSHIP®# LLC I #11111111111
COMPANY NAME M (`t IQ f) fell_ ADDRESS C1 (Li(/'Ci( 1( C) ( (; �(
CITY \A) \I 4,t An.o u '_ v l 1 STATE 11, `4.I ZIP 0 7& 73 TEL 7 7 L. D m ` w,,,,,T 1_
FAX 1 CELL i EMAIL `-- ° IA
C p L op. dill .
•
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT D 111
FEE: $ PERMIT#
PLAN REVIEW NOTES
4.00.
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- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ri L� N{
i I CITY , 7-M(J ul. . d 'C' I, MA DATE!l L IT.
[ PERMIT##/--0P O
JOBSITE ADDRESS 17 4 , 0.7. r o a I H Z D-I OWNER'S NAME 12 e C{d u i ,
lJ OWNER ADDRESS _...._._ - - -- TEL7 O O- TFAX~ 1
TYPE OR OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL
PRINT 13 RESIDENTIAL ,
CLEARLY NEW:,J RENOVATION:;L3 REPLACEMENT:ja PLANS SUBMITTED: YES J. NO X
APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _J.. . i. 1_.___1 I_. I 1 1 �. I. I
BOOSTER _ } I. E r I_1 . ._ ______I__I_ __1
I_.-_ 1_1 I I
CONVERSION BURNER I I I 1 I I._I 1.-_I- I: I_ i_____1.____Li-J
COOK STOVE I I ''_ I__I____I:__I'__J__J_ 1 I
DIRECT VENT HEATER I_1____1_.1 I i-J -t-J __1____I .
DRYER- :__`_�: ' I-I- I - I"-1 I I -1 I -.._ I
FIREPLACE I I_1 it I I.__I 1 I__. I _ I.__
_ill I I I
FRYOLATOR -(- ti—_I ____I-
_: I.._-.. _.I I f , _ I I —
FURNACE _ 1 f__i I `I --'---1 --_-I I
I GENERATOR
!". . 1 t I I -
I I I .. . .I ---1 I I
GRILLE ___I 1_____I —__.f _ 1- _ _I I i__J —I j.
INFRARED HEATER -_� . -J _-1 ! _ 4,__ -� I- _____1 (_L I
LABORATORY COCKS
I i i I._._.J ; I I. I____I_ I. I I I I
MAKEUP AIR UNIT - --- _; .__-I I,�� ______1 ____J _I I �_i I i: 1
OVEN _I I i I. t J _ i I I I . ._i. ._._.J i
POOL HEATER .____I _ -_.__.__1 -___I ______I______I_........I —._,.., I I J_,_-___ _!___________I______I1� . i
ROOM/SPACE HEATER M 1 1 I -f i I i i1 - ;_ i i 1
ROOF TOP UNIT .,.I 1 1 I I I I i - 1 1 I
TEST _; J.__ _1 1 I 1 I
UNIT HEATER ____I I I 4__.___' __-__1_—J ______"s` .1 ' i
UNVENTED ROOM HEATER _____ _1, .. _______i _ LJ .0_�I ___3 I I __
WATER HEATER --- _ ---..._ II I i I __
I ._I ; I I 1 1
OTHER 1 1__; 1 I ._. ( I I 1 1—___; I I ; 1 1
r I. 1 I _____I I___i—_i'__I . I_ I___-_-_ ___1 I: .
_, t I _
�� I��1 __ _ I � 1 1 --1 - 1 _ ' i
INSURANCE COVERAGE
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ltd NO 7,1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY lk OTHER TYPE INDEMNITY -f 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 :T-1 AGENT ..._.I
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 Coe and Chapter 142 of the General Laws. a n
�^ I ,
PLUMBER GASFITTER NAME t I �& [C R L I LICEN E#: I i IGNATURE
_
_ PARTNERSHIP # LLC j#: I
MP ,_I MGF', 1 JP JGF I: LPG' J CORPORATI N!�# I `x/
I ADDRESSr i l/`,
COMPANY NAME; (�--�` (,, �� t � gusric 6 _
1,stCITY V) ar V 0 J I. STATE�Mi 'jZIP 6 Ztf I `7 7 7 "-��� d 7/ _
!� TEL
FAX i CELL (EMAIL:
(' ii4*/ O
U
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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