The URL can be used to link to this page

Home My WebLink AboutBLDP&G-17-006568 • MASSACHUSETTS UNIFORM APPLICATION FORA ERMI TO PERFORM PLUMBING WORK CITY /C, r rVL o U MA DATE 6 ! ` ) 7 PERMIT#fr --/-7.-11:43746:- ., JOBSITEADDRESS ?0 'l� OWNERS NAME eA Qrsd'1 OWNER ADDRESS 3 O TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL". PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:V►A 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) 1 KITCHEN SINK LAVATORY Ca ROOF DRAIN W/j Q1 I SHOWER STALL SERVICE/MOP SINK TOILET URINAL . WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. • CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT LLI 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 irkcompliance with all Pe inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0401(",/1tCi/ /'jl/)r PLUMBERS NAME LICENSE# a ( L,, L( SIGNATURE MP❑ JP I'd CORPORATION 0# PARTNERSHIP❑.# ll LLC❑# COMPANY NAME ye 7h e P!Um er ADDRESS 6 (SOX 3 .5-02 CITY ea r� STATE MA ZIP O 3 1 TEL ..ova ' �7� J d8 3 FAX CELL £b( cl 3 EMAIL • ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • ke 0 CITY J 1 t nil c,c14-1^ CD f f #/WP77 06(p6 :ki . 1�4,�. DATE 1 � P_RMIT.� JOBSITE ADDRESS A OWNER'S NAME / 1 j Leff. rsoh OWNER ADDRESS cD U t (a TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAI.Lg. YET CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:1:25.. PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS BSM 1 2 3 I 4 5 6 7 8 9 10 11 12 13 I 1" BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE _ INFRARED HEATER. LABORATORY COCKS I.LN 14`7-7.11 MAKEUP AIR UNIT OVEN 1� POOL HEATER /(-7705 ROOM I SPACE HEATER ROOF TOP UNIT TEST -. F . . - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ OTHER II 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES K.NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE.APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 64 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 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 Hance with lall lPPerti ent provisign of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c • "ry Perti PLUMBER-GASFITTER NAME LICENSE# l be u SIGNATURE MP ❑ MGF❑ JPJP-JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP CI# LLC❑# COMP -1 NY NAME Q`L' I ''t-e [)[ U iv 0 B�,DDRESS : Co? CITY O r STATE L'`A ZIP O P 2 tiP TEL FAX CELL V 18-3 a. 3 EMAIL a/ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTEg Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT tt PLAN REVIEW NOTES