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HomeMy WebLinkAboutBLDP&G-19-006896 MASSACHUSETTS UNIFORM APPLICATION FOR A ER IT TO PERFORM PLUMBING WORK ff•. ` . CITY V - / (Nl.©t.) MA DATE PERMIT#/L f7 /?-ex)G JOBSITE ADDRESS /6 . 4- 5 LA-r-Q4j OWNER'S NAME," `_'// o„244/ n,s OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL17.4 PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:` PLANS SUBMI I IED: YES❑ NO gr FIXTURES 7 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 E V ROOF DRAIN SHOWER STALL _ SERVICE/MOP SINK -NO 4 2 TOILET _ URINAL B tl i)is_G L -444 NT i WASHING MACHINE CONNECTION 5Y• 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 W NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 14 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 LICENSE# SIGNATURE MP ❑ JP 'l: ((?(.5(/ CORP TION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAMEA G ADDRESS 7 /G .7.-7C I`! CITY q f/fr/CJ✓i_t/( STATE_1v1.4—SIP TEL `92 FC'd �i'/?:z FAX CELL EMAIL n 77'Iq-e". Lh cJ? T J vv LC.(2) MASSACHUSETTS UNIFORM APPLICATION FO A P RMFT TO PERFORM GAS FITTING WORK 4• ,_ - — C � MA DA PERMIT ,�F'�an`. 0.4 CITY JOBSITE ADDRESS OWNERS NAMG ��16� i���� OWNER ADDRESS TEL FAX TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:V PLANS SUBMITTED: YES❑ NO APPLIANCES 1 FLOORS-4 BSM 1 ? 3 4 5 6 7 8 9 10 111 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR COCKSGRILLE INFRARED HEATER LABOPJATORY . , MAKEUP AIR UNIT E . IV --OVEN • 1 ROOM I SPACE HEATER TIN �� ROOF TOP UNIT _ :U.IU) NG_U: PAR UNIT HEATER UNVENTED ROOM HEATER .yOTHER ■ WATER HEATER / . I 1 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 g 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 ❑ i. SIGNATURE OF OWNER OR AGENT ',I, 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 Li 'Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP l MGF❑ JP gl JGF ❑ LPGI ❑ CORPORATION ` �AR � / ❑#F PARTNERSHIP/ ❑#r LLC❑# l COMPANY NAMEVAU !mot r „0 ADDRESS 6 �C/ 5 6 C ( cite CITY �/4/ 1.'.' 4/A. . . STATE ZIP O `—'c0 l 3 TEL y (C) 7/2i� FAX CELL EMAIL t1 r, c1p d► AA-IL.( 14 a1c_, tEci 7 1 IRAN i '1 i f&r1 1i I 1 I 1 i I 1 I C) Xo I 01 a a a cn 4- Elf Eris < T I- ul t I 4 1 0 W cio 1 I C, 0 g i 1