The URL can be used to link to this page

Home My WebLink AboutBLDP&G-18-006041 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK Lam: CITY ��VM(�(;.'� MA DATE L) "2 1 ` 9 1 PERMIT# 00/'�?'aO a/( JOBSITE ADDRESS et --retP 4 (RA , OWNERS NAME L A C'®GC,CA OWNER ADDRESS 5 et INft < TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®� PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:� PLANS SUBMITTED: 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 , i i SHOWER STALLU Lj` t 0 • SERVICE/MOP SINK 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 MGL Ch.142. YES Fa NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE E 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 it 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 complianc wi all Pertinent gfovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J� I PLUMBER'S NAME LICENSE* 10 l a. SIGNATURE MP pr jp ❑ CORPORATION PARTNERSHIP❑.# LLC❑# COMPANY NAMEjj�� 1 Lt Ue s `U. (G? V1 ADDRESS 1') / ! tI/I S i 6 ) CITY C ( " 1 vs G L It1 STATE D Q. ZIP 8 9 4 to 4 TEL ,6C*. 3 7 q r � FAX CELL *Gi1/Yl EMAIL AV�¢YM1 F� O z z 0 U W at z a z oD z >� o u Co U ¢ w CO O > - CO 0 0 1111 _t R Q cry = W LL 0 z 0 U aK C7 ar O s<. MASSACHUSETTS UNIFORM APPLICATION FOR A. PERMIT TO PERFORM GAS FITTING WORK jr i' ,e,' CITY Y.[tY Uu C.) L t// MA DATE ( -) F PERMIT# L-pP -aG 6.6,y/ JOBSITE ADDRESS Lig / u t C ' OWNERS NAME G�rkt'G OWNER ADDRESS _S 41A - TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL I7 )P&IPd')! CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-1 FLOORS-4 6SIkA 1 2 3 4 5 6 7 6 9 10 '11 12 13 I 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER e J LABORATORY COCKS .40 MAKEUP AIR UNIT OVEN 1' POOL HEATER t� ROOM!SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER r i OTHER I f INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IEKIO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge 3, and that all plumbing work and installations performed under the permit issued for this application will be in compiiancy wit all L/Perti i t rovi�f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# I5 )q SIG ATURE MP 127MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERS 'P❑# LLC❑# T 1 COMPANY NAME J (JV e1-r P UM ADDRESS /71 1.l i he(6 u) --v- sc, R I CITY YicV VYr'brj. i ci , STATE M 4- ZIP 6 2 1, L9 TEL ,jc)j 3 3 7 36 FAX CELL EMAIL ea c 2 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT ft PLAN REVIEW NOTES