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Home My WebLink AboutBLDP&G-17-001451 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY WO' fW III tl MA DATE �� PERMIT# �r�� -��`�� JOBSITE ADDRESS •3b 11114,A:1'44' )j 12/11OWNER'S NAME 140,44). [:/ OWNER ADDRESS )'i ''W , loss, k.4 TEL 1,0 a33-0 ) FAX iNONi; TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 11/ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:ri PLANS SUBMITTED: YES ❑ Naipi FIXTURES Z FLOOR-4 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 I 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 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 T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 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 tr e and accu the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c pliance w' all ertin ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME tAtiVeki. O&1 J^jr LICENSE# S ATURE MP 11( JP d CORPORATION❑# PARTNERSHIP❑.# LLC[+'# 32.y nio COMPANY NAME A Mt, l V'4,�� ADDRESS 40 14" Rd CITY 046-'A STATE firZIP Olt TEL �01 3-O FAX 04. CELL V 1 1 U;3'O1.O1 EMAIL C Alt QL,J SF41 t k e yt(./10.(L�'1 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT ft PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A RMIT TO PERFORM GAS FITTING WORK '3 ram ' y� t+ /� CITY MA DATE I PERMIT ' i-00/5/,'57 JOBSITE ADDRESS 3 16 OWNERS NAME l'itvmI, L1;4 t OWNER ADDRESS JU 4 TEL 1p11& O 6061 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL I? PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: / PLANS SUBMITTED: YES❑ NO Ff APPLIANCES-.I, FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 '11 12 13 1 14 BOILER _ BOOSTER _ CONVERSION BURNER COOK STOVE _ _ DIRECT VENT HEATER DRYER T ' FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE _ _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT I OVEN li POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of Ch.142 YES /NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [v 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 accurate to the of m nowledge and that all plumbing work and installations performed under the permit issued for this application will be in co Once with all Pe ' provis' e Massachusetts State Plumbing Code and Chapter'142 of the General Laws. PLUMB R-GASFITTER NAME, M A�`�I a. D Como'r J{ LICENSE# 'IGN E MP r1GF/ JP JJ(G,F(�LPGI CORPORATION #> PARTNERSHIP # LLC It32Vcf COMPANY NAME 166 UIklc fivin ‘vuli7WX ADDRESS 70 Mal CITY D , /16t W1 STATE /14) ZIP 0(.07,j_ TEL 07 b 5 3 "O O FAX t %u CELL Gil t13>-vxvO`1 EMAIL qba-:27Urtb 11 add y4-144;i. (vie-) ,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 ' r