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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_ti lly,e CITY sQ G 1' / 6 c,t-�2__ I MA DATE 7 X- r F PERMIT#/ $OP-' -c 7 ryJ 7
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JOBSITE ADDRESS f-(U 1144 f- IADf 4— OWNER'S NAME r ydl /A-- 13 U Mt (--S'
P _.OWNER ADDRESS I TELTELIFyT 774, Q 28 AFAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:® PLANS SUBMI I 1 ED: YES® NO®
FIXTURES 7 FLOOR-, BSM 1 12 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB IOW ____IL.._.IL_ IL. L 1 1 1 4_ ___'
CROSS CONNECTION DEVICE ___L ___,L__ . ' -- -. ._ . L._ e� I I- ^i_.__Ji_. .L „i
DEDICATEDSPECIAL WASTE SYSTEM __ t _ L_..__. 1 —1 .i= h__,JIM
DEDICATED GAS/OIUSAND SYSTEM [_ ___1„( J L �1 ..._. _ 'I _J._I ' _ NMI_ .L i-___1 LL_._JL
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM .- ____� 'I J_,. NNW= i v ���'
fir— _ - __
DEDICATED WATER RECYCLE SYSTEM P, __ _ 1 ..•. I .. -._ _L�. I N
DISHWASHER ' .____ e d _ .1 L�-:I= . .i '- -- ,L��.. •
DRINKING FOUNTAIN I _,4 I �_,,, t - 'L '= _1= _'
FOOD DISPOSER I_ ae., (- '1 ( J I - L , 1._� 11 _ '_ _
FLOOR/AREA DRAIN 1_ _ _ _ L__._,�'1 _ 'I _ 'L .� _'I�.:
INTERCEPTOR(INTERIOR) I--[� I _ _.. I - -
KITCHEN SINK 1 I ! (L ,
LAVATORY iL Al. _ II i e , _ (
ROOF DRAIN ' _ i -1I _ _ _
SHOWER STALL ( 4 _ :I E I --,J L��Ji 1_ L J I T L
SERVICE/MOP SINK ' _ L,„. 1-J I _..._.�(� 7 l _ L IL. [ (
TOILET I 1i -�� -_____ - - 'LF_ -L. I _LA! ..Wt_� . _
URINAL _ L_...,� I _ 1 '�. _1...�..I _ f` .�_ _ lL.,.__-' 'f_...._.�
I
WASHING MACHINE CONNECTION 'L, _ , I___ (I�. .JL.�____IL�.n.:l_-_ __IL___I.�. ___ __1
WATER HEATER ALL TYPES - .i _ ' li I �_1'•. II .L_til --!'
WATER PIPING L_ . i .. I - $ _ _9L., it _d' __ it -- —1
OTHER _m_ I . _ � �.-�.
'' Mt __F; _. _ •_ _ _s _ _111.1- il 1. ._: __ .N ___ __UMII _11: - MLA' [M--1,_, _ i___ _L_____I=M____J_ _ I______1 .ing
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO J
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 2 OTHER TYPE OF INDEMNITY ® BOND El
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 1 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. 2
PLUMBER'S NAME V, N ti--- LICENSE# _( �� T I SIGNATURE
MP® JP V- CO P CORPORATION # _ 'PARTNERSHIP®#, LLC�#
COMPANY NAME IM,J r/Se 4-44- ;ADDRESS j A c - .,e_ l 1
CITY •\l'Gl Nvi.Q 'STATE VA- ZIP 0 1(.Q (P y TEL ) 1 t-{ �( 0 9( 2.Z; I
FAX 1 CELL r 1 EMAIL c (• cam,r s •M c 13 P ,oQ ' .A�4-l L•(c A I
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No _ _
THIS APPLICATION SERVES AS THE PERMIT EjLi
FEE: $ PERMIT#
PLAN REVIEW NOTES
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7j
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e \ � /.L 1-i / 1 PERMIT# ( -t9 / -0 / [
4_L CITY �" M-% c! C M Lt� y MA DATE
JOBSITE ADDRESS- !y / (/J ci-i i L_ �TI OWNER'S NAME i� ,it 2l 6 CJw-f cif
OWNER ADDRESS �D
I TEL �7.7�0 a 2�71,FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL) EDUCATIONAL J RESIDENTIAL t
CLEARLY NEW:J RENOVATION:'LI REPLACEMENT:,.#GJ PLANS SUBMITTED: YES D. NO
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 1_ 1_I 1.____I I_ I_I_J_ —'-11
BOOSTER I_ I 1, I I 1—J'_•—1 .—_____[____I -J I
CONVERSION BURNER I 4 1 1 I 1. 1 l 1 _ j______I__I_ __I I
COOK STOVE 1 I - L_i I_ LI :_—�-______I�_ I I
DIRECT VENT HEATER i _ I-_J_I, t ._.. .I .. i _1____I
I_ ..1 1- ... i _ r
DRYER• _ I _ I I I _1: 1-4 1 _j._... .._.i 1 1 1 i
FIREPLACE - - _I I I _I I•
I I 1 1 __ I _._I I_I 1 I
FRYOLATOR _1 1 I , -1 .. _ I 1 .. 1 -1 1 I J—1
JFURNACE I I I'. I_!—I 1 1 —J _____1__-__1 .-_— I
I GENERATOR
- I. I: I_I I I I I 1 1 1 i
GRILLE I I I 1 I ! _..-J I" I 1_-__ ;_._ J I.___J
INFRARED HEATER I I__I —1 . _ J I-1 - �'_
LABORATORY COCKS 1 1, i I-.__.__I I I I_.___.._..__ _._I I_ _I.__.__I I_.._.__ __-.
1 J
MAKEUP AIR UNIT _-_J 1 1 I __- , _I 1 1__f 1 I
OVEN I ...-__I J I I - l j. ! �..J I'_.._..._1 i._..I _�_I
k POOL HEATER I I_ I ^� (
ROOM/SPACE HEATER I I ___! 1 1 ___ `____1 I____J 1_� i _,
ROOF TOP UNIT - ••1 I I I 1 _1 I, r ) , t L I. s.
TEST I 1 I _.I i- I✓) f
UNIT HEATER I s1 I__ _ ��—s __.�' I_____.1
UNVENTED ROOM HEATER I 1 1 i�J _J_1______I 1___ 1 I I
WATER HEATER ------- - 1 /. I.. . . t 1 I 1 r�_I-__I_ 1 1 1 I
OTHER I I_ i i II. I I 1•" I I_____I 1-J 1 _
1
1 1 '_�-I - .` __ !__I—I I----I
F_ 1 ._; i l 3 1 f r I I
t INSURANCE COVERAGE
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES at NO 1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY J 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_I 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. � A \ "�PLUMBER-GASFITTER NAME &t(,.D ;1 de - I LICENSE#1-i I S GI NATURE
MP J MGFJ JP` JGF { POP-CORPORATION sI#7 — --- J _.._.
LPGI�P � p(�'i �PARTNERSHIP_# LLC #:-
COMPANY NAME'1 U3 C I cxu P 'f'---C7 --- I ADDRESS --
- --- A -
CITY (,/ CI t jvk U L../ I STATE1; ZIP )7 y S (r) ? /Z z
FAX j CELL.
/ - '
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT LI 0
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FEE: $ PERMIT#
PLAN REVIEW NOTES
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