The URL can be used to link to this page

Home My WebLink AboutBLDP&G-18-005252 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK it_ , CITY ttY UAL,t4 1k MA DATE 3 ( PERMIT#/ /1-41-aa 67A 5 JOBSITE ADDRESS .7 5 Csata k4 ti' OWNER'S NAME 1311 M cl Yt il.-- POWNER ADDRESS_�(��t/1 tit_ FAX 0 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:2"-- PLANS SUBMITTED: YES ❑ NO❑ FIXTURES 7- FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 j 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 I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE!MOP SINK I TOILET 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 Mt L¢Gh.142. YES O DJ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO 2018 LIABILITY INSURANCE POLICY [ OTHER TYPE OF INDEMNITY ❑ BOND ❑ A� OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requ jay,:; : ; . ,;;:fi T., 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. 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 compli ce ith all P rtinent provisi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER'S NAME LICENSE# 6a7 SIGNATURE MP[ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME kV�� s ?(u i s L) �I y ADDRESS ''L? 11 IV I v)S L w es-NadicF�J• CITY S r iv'Wt4,14 STATE 4 r ZIP 6 2 G G L{ TEL _Co 23 7 FAX CELL _j ONE EMAIL � _r. �� ` '2 L C-O 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 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` w' 6F CITY v C, MA DATE • 'Z I — 2 PERMIT# A'49n 4""OIK2Ck JOBSITE ADDRESS -.5 S C 51-, OWNERS NAME OWNER ADDRESS 5c jM e TEL FAX TYP OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT ®� CLEARLY NEW:E RENOVATION: ❑ REPLACEMENT:( PLANS SUBMITTED: YES❑ NO❑ i APPLIANCES a FLOORS-I BSM 1 2 3 1 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER —� CONVERSION BURNER ' COOK STOVE DIRECT VENT HEATER DRYER • FIREPLACE FRYC)LATOR FURNACE GENERATOR GRILLE I INFRARED HEATER —� LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER • ROOM SPACE HEATER ROOF TOP UNIT TEST _ . UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER _ _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of M L.Ch.142 YES 'NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BEL aJU .w I LIABILITY INSURANCE POLICY 2- OTHER TYPE INDEMNITY ❑ CONc 1 201E ' j • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required I k a flee- ,nt fly Massachusetts General Laws,and that my signature on this permit application waives this requirement. � � ' ' �E_F `RTMENT CHECK ONE ONLY: MI ER ❑ AiENT ❑ l SIGNATURE OF OWNER OR AGENT CC -/g7 yD j • 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 wit all Perti e pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ! PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP ! MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION # PARTNERSHIP # LLC❑# COMPANY NAME 'G[-UP Y \utAA c)l tq� i ADDRESS j 7174 1.6 vl i f.J L�V'/.��( f C, CITY J, 144 0 CA-i /1 C STATE 6. ZIP G Z ,4 '( TEL FAX CELL ✓0(lA t' EMAIL v 'e 1M ... " ' I .. I I . I Gl 0 1 0 hM I CJ W 0.( I Gr, uM I I 4 I I j I wa H i L G1 f— or./ w Cl Q r4 1 Cl) A CO Q DA 6L.1 f- i'"'1 a_ 6t3 U 6 Cl'-1 HC Z 0 C) 1 I up 1 h...., 1 up C, I = 1 CC, 0 g 1