HomeMy WebLinkAboutBLDP&G-19-005628 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY w \ICt rA' 0 11 Ivl MA DATE U 2 9 PERMIT#1%L4199-616�v�
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JOBSITE ADDRESS 9 !u) STD = 0 C j J OWNER'S NAME j ,%oh L 4/j G`
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL K-
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:)( PLANS SUBMITTED: YES NO lu
FIXTURES Z 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
_
LAVATORY
ROOF DRAIN #/3?o 4/({ a
SHOWER STALL �j'
SERVICE/MOP SINK y-t
TOILET 1w_ .. .
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 9C NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY JC 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.
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
,M Ql f &.�� r "` )4) LICENSE# C�( SIGNATURE C L�
MP JP pc_ CORPORATION # PARTNERSHIP # LLC # ,p rd p,
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COMPANY NAME r tP1-�4 ADDRESS q 2 UST7 C r
CITY \./\,J G. rn'L p S STATE ZIP O 73 TEL ) 7 Y
FAX CELL EMAIL 5-1-1/10 r/. , ✓1,‘.C_ �`; 4_10 3 , C
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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1 =� CITY I ._., - 1�G t, �1 MA DATE14- / (PERMIT#l�L/�/'/� �'�a�'
JOBSITE ADDRESS;_ I 1-i I L r { �'�- l OWNER'S NAME UO'P `jp 11 L Y!�C �7
GOWNER ADDRESS . _ --- TEL FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL;) EDUCATIONAL J RESIDENTIAL`;),
PRINT
CLEARLY NEW: J RENOVATION:.0 REPLACEMENT:21 PLANS SUBMITTED: YES J. NOI
APPLIANCES Z FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER J.. 1 1 1 f !. I ! `•-1_I_.1_�—J
BOOSTER I I- I I r I. I
1_. —J—J_
CONVERSION BURNER i. I I I 1 t. I'. I I_�'_I_I_I:_}_I
COOK STOVE l I - ,, ( C I- -- I :-1_—_I —1
DIRECT VENT HEATER ! _ I I i• I k—i_-_ . _1_ . . -I—!_ _I
DRYER I I I I __:.. i . I__ _ __ I -I- I __ I I ..._.. I
FIREPLACE 1 I I .- 1__. _ _I I-_
_, t .. _.i. I_ I i , I i_�FRYOLATOR I !. ,
FURNACE I I. ! I I _� 1 1 . i_ 1. --'----I ---i I
I GENERATOR t I ._ i 1 ; I. . .. I I
- __
GRILLE _i - f 1 1 I ` 1:__._.!' 1 I--_i I -1..___._i
INFRARED HEATER -1 ---i,.---- -I I ,_i ...__i••_1 —J _1—! —� f.
LABORATORY COCKS
. _
1 {. 1 ! I I I _I_ .__!___i_ !__I_J i
MAKEUP AIR UNIT .._I 1 1 -_ I I____J:
.i I . I_-1 I.
OVEN 1 I I I I*
I .I I _.____ ______I- i , _I _.ai I
46 POOL HEATER I . 1 I I l _ __1 '_._-__I___._!_I_ __e I__-___I_._�
ROOM/SPACE HEATER 1 I_ -_I I . i I _ I_ ; I i -- I._ i I___I I
ROOF TOP UNIT i r : I I _ I I I I I
TEST —.1 s. I__j ._.I_ r -,Ir I i _
UNIT HEATER i _ I �' �i Q. .3. 1 i
UNVENTED ROOM HEATER i, j ? M ___ __i____1__j �i 1
WATER HEATER. . .._ - — - I ✓. 1 1 1 1 } _I I I I 1
OTHER : 1 1_ __1 1
� I I -1 I'.�l I r
l_i
r' 1 - ! i 4:' -------- — - .- -.. ' .
! I--s '�I_o_1 I_ I I ,�_
_r, i i- 1 I i i i _i I
INSURANCE COVERAGE _
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IX j NO ;J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 11 OTHER TYPE INDEMNITY _[ BOND r !
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 ?_I 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 Code and Chapter 142 of the General Laws. \
7
PLUMBER-GASFITTER NAME I LICENSE#-I 1fl +SIGNATURE
MP ,_I MGF'D JP JGF J LPGI.J CORPORATION;_!#' P r'u P f PARTNERSHIP I# �..
C LLC. #: ._ _
COMPANY NAME CJ !- t c- t - 7-- -- -. . - - - ---
�� ADDRESS �C�S1ZC ------...---.. __-(
CITY /u
Ci r N\ U,J
FAX STATE _.�ZIP�s (o... _._...__._ ._.
I.CELL;
I EMAIL '1 !l J ei' ,(Ni Cj3 r' cs� S i `�� r L , C D�1
o
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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