The URL can be used to link to this page

Home My WebLink AboutBLDP&G-17-002018 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK __�_I CITY l.�(� e-� ri. MA AT /0/ /6 PERMIT# ' /J/6'J7--0° /1T e 1 JOBSITE ADD ESS 6/ , iJd /.I / Z1x- OWNERS NAME 2- ref POWNER ADDRESS ed TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALIi� PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:E 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 SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES I WATER PIPING OTHER r� _-___.. '-, INSURANCE COVERAGE: tItrave a current Iibbility insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2/NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW MIN I LIABILITY INSURANCE POLICY DKOTHER 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 Ili Massachusetts General Laws,and that my signature on this permit application waives this requirement. C3: - t . �� CHECK ONE ONLY: OWNER ❑ AGENT ❑ m '-'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 nd ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli with ,�,I inent provision of the Massachusetts State P u bing Co and Chapt 142 of the General Laws. f ,7/ PLUMBER'S NAME /!1 Li� LICENSE#/ �D�� . SIGNATURE MP Lam" JP❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME / iG4-i ("arc( ()1L41 ADDRESS ;7 V di ihtt CITY CI4cfId-' STATE'1 4 ZIP 622 ',C. TEL SD) ZJ 2-1 a3 FAX CELL EMAIL I 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 e�t �w CITY v ///j(IQløs7L MI AT / 9 ! PERMIT# 10X_OP-/7-OOaO/S JOBSITE ADD S 6 b41 04 S OWNER'S NAMEJC S G Y OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: Er7 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES J FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14 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 - T ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER J _ OTHER rc7 INSURANCE COVERAGE hen-current Iia "lity insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.'142 YES NO ❑ ►r: I IF YoU::Ck'IECKED' S,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW 1 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 assachuset9ts General laws,and that my signature on this permit application waives this requirement. i_ � CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1 m-, IGNATURE OF OWNER OR AGENT I hereby c t all of the details and information I have submitted or entered regarding this application are tru: an'' accurate to the best of my knowledge and that all plumbing work and installations pe fom�ed under the permit issued for this application will be in comp % ce wi y, ertinent provision of the Massachusetts State Plumbing Co e nd Cha r 142 of the General Laws.tu � PLUMBER-GASFITTER NAME �Cl 4 LICENSE#110/2 . :AO IGNATURE MP VMGF❑ P❑ J ❑ LPGI ❑ I O ORATION❑# PARTNER' P❑# LLC❑# COMPANY NAME ! ADDRESS 77 eaims,4I CITY ,e'!/f STATE iNf't ZIP °245? TEL S G'L; I 7h3 FAX CELL EMAIL 1 ---------------------------------- --------- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 'yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES