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Home My WebLink AboutBLDP&G-19-006659 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =_ CITY l/(I\Y PA.Q U\ A MA DATE J ,I 3 J / PERMIT#� -00 lG 67 JOBSITE ADDRESS 3 C/A r u e t- i 1 ( la ,OWNERS NAME Kir k' h S OWNER ADDRESS 3 Q Vrl Q TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: E RENOVATION: ❑ REPLACEMENT: PLANS SUBMI I I ED: YES❑ NO❑ 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 ROOF DRAIN SHOWER STALL _ SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 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 71 NO ❑ ! IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY e 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 1` 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 corn lance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Imre j LICENSE# J 52) q' SIGNAT RE MP ( JP❑ CORPORATION u ` PARTNERSHI ❑.# LLC❑# COMPANY NAME b, EVr I u 1 iA cr ADDRESS 47 t 0,'lost cg.t1 Y ` CITY Kor W10l✓1 STATE ti16, ZIP 2 17 / 1 TEL 52cg"•33 FAX CELL ✓4 c5 Z3 7 33 / EMAIL SLIP M 4 — I 2._3 g2 c tipa' ( G C'C4 • COik c \ D 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 \ ;� �_�� MA SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = moo �, CITY VGIYst1A t: V MA DATE 5- - 3 --I 1 PERMIT#/01-0, 'a9(6 l JOBSITE ADDRESS 3 6 C.WeLie. ('+; It a d . OWNERS NAME Ha y n,y% 5_ GOWNER ADDRESS S GO'_ TEL FAX TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL Tr...... PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES❑ NO❑ 1 APPLIANCES-L FLOORS-- BSM 1 2 3 1 5 6 7 8 9 10 11 12 13 14 j BOILER —� BOOSTER j • CONVERSION BURNER COOK STOVE i DIRECT VENT HEATER -i I DRYER i FIREPLACE FRYC)LATOR FURNACE i GENERATOR GRILLE 1• INFRARED HEATER LABORATORY COCKS •� I MAKEUP AIR UNIT _ OVEN POOL HEATER 1 ROOM/SPACE HEATER I ROOF TOP UNIT TEST .•. . . ,irh- 2 3-4 UNIT HEATER UNVENTED ROOM HEATER __ WATER HEATER I OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU.Ch.142 YES ND ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TI-IE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ar OTHER TYPE INDEMNITY ❑ BOND ❑ • OWNER';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 sit, 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 `k- 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.;`t fC- liii:A PLUMBER-GASFITTER NAME J CO( e ) L I %eV' LICENSE# (5). j q SIGNATURE MP ! MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑if PARTNE .SHIP❑# LLC❑# I COMPANY NAME J O-V"ert•C ?_3 r`}.Iryt l 11lA ir ADDRESS � 7 it Lth l(N '<cf-Lir 9,cif CITY Kt.Y'vo d \t-{AA STATE NiLt . ZIP C5 2 to to, Cf TEL 5-46 -Z?7 3 L-f I FAX CELL �'7 CkIM F EMAIL JL*Aie.v1M 1/g & Q wiat S. (Owl C , 0. L N-L (-/?if- 1 i I . C • 1 • i ri I M I it i O 1 ▪ 1 0 Cr I 1 Bait = �1 Z 73 c,r > C —I Nei O C > on n L r mi .< • -g •, I -a = Iv rn i 0 m m 2 I rz I r.� . lz7 I u o ❑o . I I I I . I I 1 1 I 1 I i I