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Home My WebLink AboutBLDP&G-25-114 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Vi 1 K "CD V fT MA DATE2 PERMIT# i3Li) P-2r- 1 JOBSITE ADDRESS 11_ i 1 /t/ftv5 7T OWNERS NAME OWNER ADDRESS TEL 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 I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL . I SERVICE/MOP SINK '' TOILET URINAL ❑ l025 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER i � J INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND 0 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 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME 5'M PtIV M GIVI ICENSE# L/> 9 9 SIGNATURE MP JP CORPORATION❑# PARTNERSHIP❑.#, LLC COMPANYNAMF L06` I�� I'" ADDRESS ,r/V Tt 40\111 --P CITY yorzklA STATE Y /l/4 ZIP e26 7 66 3q �/ r 4/ `TEL 50 36U i U�( FAX CELL EMAIL I �,,tl 4 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PER FT TO PERFORM GAS FITTING WORK � V MA DATE CITY9PFRI ITS 2/--D - a JOBSITE ADDRESS ')/2 / L/ (V E7 te- OWNER'S NAME 1 OWNER ADDRESS TEL vim= TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES FLOORS-+ BSM 1 2 3 1 5 6 7 8 9 10 'I'I 2 1� 'ILL BOILER BOOSTER CONVERSION BURNER _ ! COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER i LABORATORY COCKS —� MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of 111IGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE ECKING 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 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 compliant with all Pertinent provision of the - Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME i:: v !✓ ift M P —LICENSE# l<j-71% SIGNATURE MP ! J!GF JP GF LPGI ❑ CORPORATION El# PARTNERSHIP❑/t LL('❑# COMPANY NAME 1 (J �' (�`—� v ADDRESSZ CITY '(Ic�v(V(U 7-12( STATE V" 1 ZIP 6 '16 TEL FAX CELL, 3 6D 39g3 EMAI 1 44q 4 ( a (6 I I I G'/ 0 4 2 �d I k I 4 I I 4 I 4 . I I I I 4 7-1 �D I c a.a. C) w W s F I .. 14 c a" Ca 0. F— :w a°r -1 EM a— a.. Ili [w H G I P w 1ceD a i I i I i