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Home My WebLink AboutBLDP&G-19-003275 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK UCITY L ickk owu' MA DATE I I' �8 I g PERMIT# P19— ✓;171— JOBSITEADDRESS •41S (TIAA. UcE(k OWNER'S NAME Sal- LOCO POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL B' PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: li4- PLANS SUBMITTED: YES ❑ NO E FIXTURES 7 FLOOR--+ 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 _ i SHOWER STALL SERVICE/MOP SINK i TOILET URINAL _ . WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I - - 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 l" NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [L]' 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 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., PLUMBER'S NAME t.Qe..nnx s (• j .4.4i1 LICENSE# (mg°Li . SIG : RE MP [ - JP ❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME QI( PoiST1 P .A ADDRESS I I e P S`1.-- CITY (.1,1e CL 2,mo wcc rk STATE Ill'A 4• ZIP 0 a-6 13 TEL FAX CELL '77'/'t 4 '93y EMAIL (9.f�,�rt.e'D+h&s �GL.(k,� cr-P-0) 4q Lip Z_r/t 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 `n��_,6N CITY ekRrng MA DATE L- -- I g PERMIT JOBSITE ADDRESS 15 &{,1,n(e-1 a-14- OWNERS NAME 56( cocci OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[4.— PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: 4-*" PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-+ BSM 1 2 - 3 4 5 6 7 3 9 10 11 12 '13 I 11 BOILER BOOSTER CONVERSION BURNER COOK STOVE ' DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN i POOL HEATER ROOM I SPACE HEATER I 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 MIGL.Ch.142 YES Id ❑ 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 valves 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. PLUMBER-GASFITTER NAME D.enAt S V '- /(,C. LICENSE# ggo SIGNA - MP T' MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP❑# LLC❑# COMPANY NAME li k eatnr e4 ADDRESS jM e o CITY 1I.ia f&c. STATE YNC. ZIP 0 Z4 r 3 TEL FAX lJ CELL tirltl g36 $ EMAIL WW2— I Gt G ,co ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT ft FLAN REVIEW NOTES