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Home My WebLink AboutBLDP&G-18-006659 17--- -- MASSACHUSETTS/ UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �' -, C W L �1.� / `'� PERMIT# lle 6� __l_ _. CITY MA DAT 7/ e - JOBSITE ADDRESS ) 57 '. OWNER'S NAME AlkI IS POWNER ADDRESS Z C4 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 1!ff.-- PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:2r— PLANS SUBMITTED: YES❑ NO FIXTURES T 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 _ _ --"":",Z1 LAVATORY ' - ROOF DRAIN _ SHOWER STALL SERVICE/MOP SINK TOILET _ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / WATER PIPING _ OTHER 1 i, - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES e NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW . MAY 2 3 201 •.444),,„.,,,y - ,-.4-A.,„ iziN, t- LIABILITY INSURANCE POLICY 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-:- r 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are tr e nd accu ate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co p' nc v,{it II Pertinent provision of the Massachusetts State PI ing�,pdde and C pter 142 of the General Laws. /J/, PLUMBERS NAME zt LICENSE#rte: //d I2 . % SIGNATURE MP JP ❑ r CORPO TION❑# PARTNERSHIP U. LLC❑# COMPANY NAME / L!r` UMA / ADDRESS CITY (,G';/f 422 IL' STATE/?2L ZIP O��5 G TEL 7(j? Z( c2 2 7%% FAX CELL EMAIL /—, H 0 0 H U z c o� Z z ;❑ 0 H L UW .4 F O ¢ wa w O > pc O 0 w I � Q U J a. a. LW H C 0 H U a.< nj a2) 0 "� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . `--� t 9fi(71- th'flk MA DATE LJ v PER IT# '-4''eV '46 �.�k��"' CITY G� ; .,': JOBSITE ADDRESS I Cog 1�i/i sL I OWNER'S NAME i rdl S Aq GOWNER ADDRESS Gr - / c/ :d TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL [3--- PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE N GENERATOR GRILLE • INFRARED HEATER LABORATORY COCKS -..4MAKEUP AIR UNIT OVEN — POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST . UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER / �r� � L�� , z�3 1OTHER i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESO ❑ cc.,' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND JOWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Q 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 a d 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 com li ce 't .aIliPertinent provision of the Massachusetts State Plumbing Co e and Ct/aa\pter'142 the General Laws. I r�7r �/ PLUMBER-GASFITTER NAME ,4-! ,-/�� LICENSE#>//bil 7 SIGNATURE MP[MGF❑ JP GF❑ LPG!❑ CORPORATION❑# �j PARTNE9HIP❑# ,,� LLC❑# COMPANY NAME / Del ADDRESS 77 ('��l(in )VC, i1 F � CITY (I LI t STATE L�� ZIP (J2 637 TEL �e Ill)Z� 7 5 FAX CELL EMAIL Z-'t 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 1 I 1 � l