The URL can be used to link to this page

Home My WebLink AboutBLDP&G-24-666 17O) kte-7- 3---\-- n MASSACHUSETTS UNIFORM APPLICATION FOR A ERMI TO PERFORM PLUMBING WORK __ CITY_ /t,� U! l ___ MA DATE -' PERMIT#SL Z`OP- i 4-4-64- �, ' JOBSITE ADDRESS / IAJHI/S / II D -7-6r3 P )- OWNER'S NAME (-/G/l POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES T 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 1 - FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) • KITCHEN SINK E-C ., E \ 6 LAVATORY ROOF DRAIN SHOWER STALL Li Q 5 20,24 SERVICE 1 MOP SINK TOILET "a DING [ EPARTMEN URINAL `3Y ----------- -T j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING r OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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. `st 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 d 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 compr nce with all Pertinent provision of the Massachusetts State Plu bing Code and Chapter 142 of the General Laws. 6f�' -'-c0PLUMBER'S NAME 0 r /'' V' UiLf v►�LICENSE# 19 SIGNATURE MP JP CORPORATION 1911I# PARTNERSHIP❑.# LLC❑# kitTfo��ti a& COMPANY NAME � ADDRESS Cam-, / � CITY G�Lt'' -l�� STATE /`��/ ZIP 0 -7 TELf3s ✓CO� - 9 FAX CELL EMAIL hI/01464a `G'f/w,`� EI. C.C-44-x_ 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 oc c- i.ri4 , 1,2____„6_,-..., i , .„ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "^ P CITY 0,01 r7t i•/):111 'C.—T.; I� ,;T��MA DATE 7`I PERMIT# i3")()--Z-L' .- c.�� JOBSITE ADDRESS / a} l71( I C CO 7171 OWNER'S NAME 6'C-9 f-^j GOWNER ADDRESS TEL FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL EF----/ EDUC TIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENGwiTIGN: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-1. BSM 1 2 3 4 5 6 7 s 9 10 •11 12 13 1 BOILER BOOSTER CONVERSION BURNER, COOK STOVE —� DIRECT VENT HEATER DRYER FIREPLACE �— FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT —_f_; OVEN POOL HEATER ROOM 1 SPACE HEATER ! C ,0 F ' ROOF TOP UNIT 1 TEST _ LA% I. ir _I UNIT HEATER .. - _ _. UNVENTED ROOM HEATER �, WATER HEATER Ri iii1-)lNG i EPA TMENT OTHER By -- ---- . 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA . Y 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 i 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 accu ate 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 jertinent provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -L1 41 PLUMBER-GASFITTER NAME 1) p f ff mil-kr L O Obi IC CEIJSE# J6 SIGNATURE MP f —14GF❑r P JGF ' LPGI ❑ i RPORATI N❑4 PARTNERSHIP[]#� LLC❑#t J ( [IA) i COMPANY NAME U 6 0`'� t ADDRESS � ��/ � r''''' CITY Y l 1 `� 1 ` STATE_i " ZIP / 7 TEL L 7i C� -�cb V ,s Cpj FAX CELL I/ k c 4-1 q' EMAI /1/81 /( V 77 Ci 1 #t/ 0 4 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT f PLAN REVIEW NOTES