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Home My WebLink AboutBLDP&G-19-001923 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY yAS-MO MA DATE I 0 I ZO PERMIT# ✓��l �/�1 (7' � •�� JOBSITE ADDRESS O M J -c OWNER'S NAME� Peiv' ern 1 `OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: E RENOVATION: ❑ REPLACEMENT: PLANS SUBMI I I ED: YES❑ NO FIXTURES 7. FLOOR-4 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 C1 , � URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES fl 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 NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY K 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 1` 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 al Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Sec n VAan t-�.�-> LICENSE# /G.g-- SIGNATURE MP[` JP ❑ f CORPORATION El# PARTNERSHIP❑.# LLC❑# COMPANY NAME I4an(r Pr/4 ADDRESS Po c2�')( Si? CITY Ce_ey f J l 1 STATE p'l- ZIP 02632. TEL 77q Z3b''02c FAX CELL EMAIL ha r J. ()/UM b,I1j9 MwFt- b,v' ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT it PLAN REVIEW NOTES r-- \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e=� et �i /� "^`mo o J' CITY 4G.r—Mo v MA DATE 10- I - Zo l� PERMIT# VP--1 --06 �J 4.� 6 -1- 'f JOBSITE ADDRESS Z5 c� NIe-r5G� Cer OWNERS NAME Pe.G1-ve-mad 4Z. OWNER ADDRESS TEL FAX • TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 1l PLANS SUBMITTED: YES❑ NOit( ! i APPLIANCES FLOORS-F BSIJ 1 2 3 1 5 6 7 S 9 10 1'I 12 13 14 BOILER —1 BOOSTER I CONVERSION BURNER I COOK STOVE DIRECT VENT HEATER I ' DRYER . i FIREPLACE FRYOLATOR FURNACE _ GENERATOR. GRILLE 1 INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT —i OVEN POOL HEATER • { T P l ROOM!SPACE HEATER ROOF TOP UNIT 4 , ci /44..._. :... TEST -.. h� v 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 NIGL.Ch.142 YES & NO _J 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. 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1 •� SIGNATURE OF OWNER OR AGENT j 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 rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `1 '' rr PLUMBER-GASFITTER NAME Se - ka i r -kc:.n LICENSE# /5gr-22_M SIGNATURE MP KMGF❑ Pet ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# 1 COMPANY NAME I-tan 1A-^ e+14 ADDRESS ea GS 6 CITY e `f''eX\fAt.x.,, STATE (nit ZIP 0z‘i3 2- TEL 1-74--Z3S--O agfc, FAX CELL EMAIL .ns'c ,n Pf VmbNyd fricct.ca^-1 ( I G2 E-I 0 I 4 1 i �d I i'''' I I I ,171 I 1 I I Z I G «0 I co ix c.4 °_Lu C) 4 a" I— I 7a I .. t . >- .. g Co . . .. C) a CoPA 2-1 LLl°i - ca. Co uo I--- it. u� I [1 0 �r 0' 1 C II CO Icia 0 0 Q I I 1 i