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HomeMy WebLinkAboutBLDP&G-17-002016 I—� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , — � (' 7T1/G1 MA DATE / ©/r• i v PERMIT# fJWIP%T"�a��I c=_1_f= CITY —.3 epiii..)1- � 14�/ j�D,� > , JOBSITE ADDRESS 7 j !Il 4)/)C L'f t, OWNER'S NAME F.,. .7.71 h, POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALV PRINT �/ CLEARLY NEW:❑ RENOVATION: [1] REPLACEMENT:L PLANS SUBMITTED: YES❑ NO E 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 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / WATER PIPING OTHER I- 7 INSURANCE COVERAGE: I I ave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES V NO ❑ i -• YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY E BOND ❑ i WNER'S INSjJRANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Iassachusit#General Laws,and that my signature on this permit application waives this requirement. I -j 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 r 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 co ianc- • all Pertinent provision of the Massachusetts State PI m ing � and Ch pter 142 of the General Laws. ,.( IA PLUMBERS NAME ill i LICENSE# 81)/Z , SIGNATURE MP Lam" JP❑ i ,CORPORATIONCO / ❑# PARTNERSHIP El LLC❑# COMPANY NAM / 4vi4 / ` �/7' ADDRESS , 014-'l3 ke_. CITY COMPANY NAM STATE /v i7 ZIP �/ Z TEL 'O1 ixZ� 2 76? 3 FAX CELL EMAIL 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 PERMT TO PERFORM GAS FITTING WORK le Ig -- .lam `T 6-- CITY 61 M,L, DATE/ /sh, JOBSITEADD ,7j- /Y $ /I, / 11NERS NAME> OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E r PRINT ❑ EDUCATIONAL ❑ RESIDENTIAL A----- CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-. 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 1� POOL HEATER _ ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER / I 1 OTHER 3 i c. Is , INSURANCE COVERAGE ' ;;;a 1 havgg current I ability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES N63 ❑ 11F Y #'CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW 0 i f- I LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ ►fJ�}WNER'S INSU NCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the f� • sachusetts General Laws,and that my signature on this permit application waives this requirement. 4 CHECK ONE ONLY: OWNER ❑ AGENT ❑ t 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 4. and that all plumbing work and installations performed under the permit issued for this application will be in oomphc th a!t'e't ent provision of the Cu Massachusetts State Plumbing Cod a d Ch) ' fI ter 142 of the General Laws. PLUMBER-GASFITTER NAME ` LICENSE#/0/2 SIGNATURE MP.e rv1GF❑ JP❑ GF❑ LPGI ❑ CORPORATION El# PARTNER IIP❑# LLC❑# COMPANY NAME 1/ I"p ADDRESS ?7 e/f) /1/ CITY C �k`r 4 STATE /`Zest. ZIP OA 63 Z TEL Celf2dg ,g7463 FAX CELL EMAIL i . Le 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