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Home My WebLink AboutBLDP&G-25-287 �.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 1/4-TA/a4/ , D.P-, MA DATE ,5 ha/ZoZ PER IT# &O P-Zr-Z 97 e% JOBSITE ADDRESS OWNERSc NAME ` (�U� 5 POWNER ADDRESS 7 7 YL C_/7 a �'�Z "FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(; PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:ix PLANS SUBMITTED: YES❑ NO ;.4 FIXTURES 1. FLOOR-I BSIVI 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 V G SERVICE I MOP SINK _ TOILET MAR 5 1 URINAL . j WASHING MACHINE CONNECTION i WATER HEATER ALL TYPES / ,I_ U t VH K vi t N 4 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESt NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE.OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE OF INDEMNITY 0 BOND 0 i 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 lei 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 thi application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.1 7 sr (' �` y —� PLUMBERS NAME PA tAN) kc (7 ` LICENSE# �l SIGNATURE MP❑ JP[i, 10+1/1! CORPORATION❑#)p0,1 PARTNERSHIP❑.# LLC❑# COMPANY NAME iJ14 ADDRESS 3 7 /(-- �'Gi/1��' r7 /%r CITY / 7 74/ / 4 1 ��"4 TE ZIP r3 �� 6 or � TEL�7 Y 7/ 7)2 Z FAX CELL EMAIL S/ _/l5,/- - M co r/i7 a9, -1 L` ( 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 PERMIT TO PERFORM GAS FITTING WORK tj 7 /- `^`-{': J�� CITY `/q: /� (' '` ' ' ' `�;�,�•s, � y � h4r, DATE ? � L �� PFRMIT# JOBSITE ADDRESS ! C0 re- 5; CG Oboe , OWNER'S NAME j OWNER.ADDRESS 'TELL 7 FAX TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:(I PLANS SUBMITTED: YES❑ NOZ APPLIANCES FLOORS—* BS1v1 1 2 3 21 5 6 7 8 9 10 '1'1 12 '13 11 BOILER BOOSTER CONVERSION BURNER —� COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR. GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER ROOM;SPACE HEATER ROOF TOP UNIT TEST _ . ... UNIT HEATER l UNVENTED ROOM HEATER I r- Z*5 WATER HEATER OTHER .1.111 Hy INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter*142 of the General Laws. / Lt.}, PLUMBER-GASFITTER NAME PI\\CIA —e L ��`C� d! � LICENSE# SIGNATURE MP ❑ MGF El JP ❑ JGF❑ LPGI ❑ CORPORATION❑# �•' PARTNERSHIP❑# LLC❑# COMPANY NAME �\ (^ i ADDRESS -2 ADDRESS ! � J,-w)L`1/' 1 CITY 6 I n I S STATE ZIP 6 Z d/ TEL 12l d /d //Z Z FAX CELL EMAIL 5 i7�E41-' in [ -r�� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: v PERMIT# PLAN REVIEW NOTES