HomeMy WebLinkAboutBLDP&G-17-000381 MASSACHUSETTS UNIFORM APPLICATION FORA PER IT TO PERFORM PLUMBING WORK
'f• CITY YFI-12114 D V / ) MA DATE 7 ‘IPERMIT#A IW-/T-0ogVi
JOBSITE ADDRESS 23 Wf -/ 6. A N 'AME DAL1 j
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYP COMMERCIAL I&I.--'------' 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
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 3/ -.. _
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equival ich meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF ERAGE 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
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 n c 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 compli I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ,�, 1 3A-!Am- -00o { � Lj- # G/ SIGNATUR
MPP / CO PORATION❑# ✓ /��PARTNERSHIP❑.# LLC❑#
COMPANY NAME FJJfqL- V Ft ADDRESS
CITY yfi--, STATE___M ZIP O2. _" TEL t ag- .,3 '0.3rro'
FAX CELL EMAIL
JUL 21 2016
_ � , ,� I1.
R �' EPARTM � r
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
' ' - ' - ^~'
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` '- - K�A����MU�ETTSUN1FD�� A��U��TK�M ����\ P���U[�� �E������A8K�T�M�VV��� �
~ VF . MA DATE —�%W E AME PERMIT#
�7%ff OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCYTYPE C EDUCATIONAL RESIDENTIAL
PRINT _..-_'_._ �� ��
CLEARLY NEVV:[lL-~~-�N0VAT0N� ���REPLACEMENT: El PLANS SUBMITTED: YES NO El
APPL|ANCES-1 FLOORS- 88IO 1 2 3 4 5 O 7 8 8 10 11 12 13 | 14
BOILER |
BOOSTER
CONVERSION BURNER
|
COOK STOVE
DIRECT VENT HEATER
DRYER '
FIREPLACE |
FRYDLATOR
FURNACE
GENERATOR
GRILLE '
INFRARED HEATER ~
LABORATORY COCKS c-
MAKEUPA|RUN!T
OVEN
POOL HEATER |
ROOM/SPACE HEATER |
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER UP.
w~
OTHER |
|
INSURANCE COVERAGE '
|have o current liability insurance policy or its substantial equivalent which meets the requirements nfMQL Ch.i42 YES [n-YO E]
|iF YOU CHECKED YES,PLEASE INDICATE THE TYPE OFC NG THE APPRDP�UATEBOX BELOW
LIABILITY INSURANCE POLICY 7�MRTYPEiNDEMN|TY [] BOND F-1
OWNER'S INSURANCE WAIVER:I arn aware that the licensee does not have the insurance coverage required by Chapter 142 of tile
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: NER F� AGENT �l
SIGNATURE OF OWNER ORAGENT �
I hereby certify that all o[the details and information|have submitted nrentered regardingthix application are true an curate to the best of my knmWudge
and that all plumbing work and installations performed under the permit issued for this opp|icati wi||b in compli t 11 Pertinent provisionof the
Massachusetts State Plumbing Code nd Chapter 142 of the General Laws.
PLU
=�~~�. -~��
�p[] � F� ION n# PARTNERSHIP LLCF�# '
COMPANY7�WXV
\��`/ � V ( \ ADDRESS 'x 1 /��� / < / ��v\�
� /r-7-� /~� r�-�* -�'�r �
CITY L/ � /�- STAT�/���1- Z|P [~�u���� � �� TEL |
5beFAXCELL [�
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
- Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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