HomeMy WebLinkAboutBLDP&G-24-636 MASSACHUSETTS UNIFORM APPLICATION FOR PER IT TO PERFORM PLUMBING WORK
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e CITY R I COMA DATE L. PERMIT
8 i Z 7 Z C� OWNER'S NAME C h A: I c%r''1c'0S iV�t t/4;d► S
JOBSITE ADDRESS
OWNER ADDRESS TEL`;rt
�3c°J�y&? FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT.V5 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1. 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 F —r 1
SERVICE/MOP SINK
TOILET
URINAL 2 „
: !
WASHING MACHINE CONNECTION
i WATER HEATER ALL TYPES J
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. YE NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY t9i 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
iz Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
V 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' ompliance-/ ith allll Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. vifil 7l r;4 ►'
PLUMBER'S NAME
(X v , >M 1.C:,--o SS i v, LICENSE# L/ (0 g q- SIGNATURE
MP ❑ JP' �1'I CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME �a ve 1 he Pi lJ M k ADDRESS P C) IS C)( �L
CITY - F C1 STATE M.f T ZIP 0 2�3 ` TEL 8-
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MASSACHUSETTS UN HFORIVI APPLICATION FOUR A PER IT TO PERFORM GAS FITTING WORK
'' 1 e CITY `� C�:'�'t )V' 4 k MA DATE 7 7.y Z-Y PERMIT 4 01- Or-'- Z 1 (- :SC.'
JOBSITE ADDRESS 9/2 R`1- 2 S OWNERS NAME hUn.jc m 1%-.25
G 7Y- Y-3(2—ZVRir FAXM41 Ia,4i`S
OWNER ADDRESSTEL
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONALII] RESIDENTIA :4
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-4 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 •13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
- i
DIRECT VENT HEATER _ 1
DRYER — I
i
FIREPLACE i
FRYDLATOR =
FURNACE
GENERATOR I
GRILLE
r INFRARED HEATER
LABORATORY COCKS I • I
MAKEUP AIR UNIT —1
OVEN
POOL HEATER
ROOM/SPACE HEATER - 9
ROOF TOP UNIT J
TEST . -Jill— 4-2f?4
UNIT HEATER
UNVENTED ROOM HEATER ui DING EP rME4d�- I
3
I
WATER HEATER ' _ --- -_ J 1
OTHER I
- i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES 0 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 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 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 ccliance wi h all P 17inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /(//77 / ]/{ ^ )O
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PLUMBER-GASFITTER NAME a.v a_ C at-0 S s ‘.'‘ LICENSE# SIGNATURE
MP ❑ MGF❑ JPJP'►: JGF El LPG! CORPORATION❑I PARTNERSHIP❑# LLC❑#
COMPANY NAME --7'et`)e Ti L' V`v‘'bL ADDRESS P 0
CITY Th PC•t- T STATE ! V I --' ZIP 02-'(a';i TEL( �Ci g --� Z 3
FAX CELL EMAIL AU.v"e @ ve° e ptoA\bor. c ( ;vv
ROUGH GAS INSPECTION NOTES TIP`PAGE FOR INSPECTOR USE ONLYFILIAL INSPECTION NOTES
Yes Nu
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES