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Home My WebLink AboutBLDP&G-006550 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ikty_/ .� a I I /�g-� 163t CITY � ��/' VIA � � L✓' MA DATE ,� - � ' I PERMIT JOBSITE ADDRESS '-I) G,c be lr 14v Z OWNER'S NAME 1 L1U') -tu e OWNER ADDRESS 3' 4 ik% TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1. 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 r' ' SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES j _ 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 +L 1 N0 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 comp nc with all rk�vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. rr q (/ PLUMBER'S NAME LICENSE# 1 k. 1 SIGNATURE MP LLT JP❑ CORPORATION# PARTNERSHIP E.# LLC[]# COMPANY NAME J �Y`th ti _ ADDRESS / 7V Wi WS lG 6v CITY KY- Wl c �- 'I STATE IN. ZIP 6 Z , G `- L TEL ,\ FAX CELL 3 a VI-v.— EMAIL 3 u 4�1��I (� Q L'i l .C ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES K8ASQACHU3ETTSUN|FORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �� C|TY �) � �� /) �� DATE - -�� PER�|T# ��-��)��[� ` �� /\ ./ �/� � // yx`�v/ � | ~"«*� L� 1 J / / JOBS|TEADDRESS /p� ��cv��Qc�t~�`�� i��V* e_- 0VVNER'SN4ME �� ~ � � � nr OYVNERADDRESS ��/��m�� - TEL FAX - TVP0OR OCCUPANCY TYPE COMMERCIAL�� EDUCATIONAL F� RESIDENTIAL PRINT ^� ^� ~~ -�' CLEARLY NEVV:E] RENOVATION: 1-1 REPLACEMENT: PLANS SUBMITTED: YES El NO[I APPLIANCES FLOORS-~ oSm 1 2 3 4 5 6 7 K 9 10 11 12 13 14 � BOILER i BOOSTER | | CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE | FRYOL4T0R � FURNACE ' GENERATOR GRILLE / INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ) ` OVEN ' --^ -----��^` / ` u"o" �— , | POOL HEATER / ! ��, | ' ROOM!SPACE HEATER '� " � | ROOF TOP UNIT [ ~ TEST UNIT HEATER UNVENTED ROOM HEATER - | WATER HEATER 0 OTHER | � INSURANCE COVERAGE ' |have m current|iobi|by insurance policy or its substantial equivalent which meets the requirements ofMGL Ch.143 Y28 FNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE-^�E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 15 OTHER TYPE INDEMNITY 71 BOND 71 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. _J CHECK ONE ONLY: OWNER [] AGENT El ~~ SIGNATURE OF OWNER ORAGENT ~` I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate m the best nvmyknowledge z and that all Plumbing work and installations performed Linder the permit issued for this application will be riertinewt ma�a��a��P|vmm�C�eo�Cxu��14u�m �o� ym|��. y _~.~ PLU�B GASF|TTERNANE LICENSE# ��u/ /7 SIGNATURE MP� M8FEl JP[:1 JGFE LPG| El CORPORATION ED' PARTNER8FrP LLCF1# | COMPANY NAME u� �V(�cv'0'S� � \ U-�� ADDRESS CITY � ' �»~��L°4- ' S�TE �` ZIP ��y � � /( TEL -' ' - - ' ^ '' ''' �� = l ` . ^� / 1 FAX CELL .^ 4\N �_ ��L /0 LIA�� ' CG � - ' � V� -�~ � � ~� `�L� 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 7