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HomeMy WebLinkAboutBLDP&G-19-005730 P PRQC-V : ! (- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY < N/i MA DATE Ja PERMIT#/ i�/�/4-�'�� 7/2O JOBSITE ADDRESS V � L���� �f OWNER'S NAME c.._C)/-/ ()at-61 OWNER ADDRESS �t SC 1it�t t,✓F�S�c.)(,i;X TEL 7 Si .,%1 S576)Z FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL is PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NO- FIXTURES 1 FLOOR-, 8SM 1 2 3 4 5 8 7 8 9 t0 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01USAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 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 1 WATER PIPING OTHER 3 6! INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:l 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 0 AGENT 0 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 Ibis application will be inwnpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME klukro C-14cint c'',-�^,;J) `3 LICENSE# C 5 3c( J SIGNA E MP;Eg JP❑ CORPORATION # LC/v C PARTNERSHIP❑# LLC❑# ' COMPANY NAME )6 PiL ".1 1/Y , ADDRESS I S" s 11nc- k t CITY )c')' 't' STATE n'� ZIP r)P- i ci TEL FAX 0-t<1 CELL EMAIL (jW;<-P -300;,�+'��t>,��//16 .v.&F a --7,, L/ 1 ° ) L. ,�` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I tit, .i CITY[ )'t'L ,ry th �. _I MA DATE'm:�_ :__ro.!__I PERMIT# N-19P--$0a 5i 7'3 6 JOBSITE ADDRESS I I &/7r'�� _' �OWNER'S NAME, �j � ____] GOWNER ADDRESS L L TE 1 01 , __,IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL Q RESIDENTIAL-J PRINT CLEARLY NEW:(J RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YESLJ NO N APPLIANCES 1 FLOORS—► 9SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ,,.,.___1 ,_. ,,,, I _, • r.,l. _}_, _._ t T..__, ...,.._ '_, BOOSTER _i!ni ti -i I, .T CONVERSION BURNER ,L� I !s 1 --�, r.:,-1 Alit:ECOOK STOVE ! ' DIRECT VENT HEATER I w , i .�,. ..�_1 DRYER s __ E FIREPLACE w ' FRYOLATOR .-�, (—� I: i I! + ( ) FURNACE 1--- 1! . ' i ` may _ IY_.#..-_1 GENERATOR ' 1! . :-.- '; 1 1. - I _ -J 1 GRILLE : ..___ INFRARED HEATER i I . . .a._I LABORATORY COCKS I_ 1 11: i I MAKEUP AIR UNIT i_JAL_ l i ' . i.OVEN c I,.. _. '_.. ! _._f POOL HEATER a. ' I, 1 ' ROOM/SPACE HEATER __,1 i; _.,,J __ • ,--I 1 1 . _. ROOF TOP UNIT I I,�_,.n. !I !: ! i_ _ I. i TEST ! !,-1 = UNIT HEATER • _ ! UNVENTED ROOM HEATER ii( i i 1 1 ! WATER HEATER OTHER . _ IMP ► i I - . • ...- , _ _ .t.ffr_SM.)11111- LIEWIIIIIIPICIICIPIWW1111119Minglin=Ms { INSURANCE COVERAGE I havt~ rit lability insurance joky or its substantial equivalent which meets the requirements of MGL,Ch.142 YES 0 NO LJ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [J OTHER TYPE INDEMNITY ® BOND El 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 a/2,P.,-/.1.-e llertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I�L___ __ -_-,, LICENSE# .?,3c SIGNA URE" MP MGF Q JP© JGF 0 LPGI© CORPORATION fJ# o C I PARTNERSHIP®#J __ ___, I LLC 1:1#I7 r1 COMPANY NAME:_,1, 5Yb ADDRESS 1('' (Vlct r17....,'t. _ ,,,,, ,.�_.. __....__.-_____.._.... , CITY .. 1- i/1 S_Pr:f-'1-___.n.=._..,___________I STATE fl ZiP[C7 a 3 q _1TEL� 3� 3 ....-..._n FAX ,5/.4)-2,cl_k(t-IlCELL ,EMAIL.( , -rJz 3 - pi f t r 1Qi" .__ . ,. ,� __.___... ___ ._1 LP /J