HomeMy WebLinkAboutBLDP&G-19-004077 MIASSACHUSETTS UNIFORM APPLICATION FOR
,A�PERMIT TO yPERFORM PLUMBING,WORK
7
t CITY ,ems y'p"P_ e 7; MA DATE J /lea'/ PERMIT#/Y�/77"�°`-)7�7
\-.. JOBSITE ADDRESS ' ' �tio"- ' OWNERS NAME %r � ,Z�
POWNER ADDRESS ,_5"-/1r�.z>"..ahz-,D.S '",l/.4 TEL '72 Q32 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Le"
PRINT
CLEARLY NEW: E RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMI I I ED: YES E NO❑
FIXTURES Z 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
III
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN -
INTERCEPTOR(INTERIOR)
KITCHEN SINK -
I LAVATORY
ROOF DRAIN
SHOWER STALL
i SERVICE/MOP SINK
• TOILET '
URINAL .
j WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES
WATER PIPING
OTHER
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ( NO 0
I IF YOU CHECKED YES, PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND 0
! OWNER'S INSURANCE WAIVER:I m 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 th st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compllI nce wi rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /ry�YJ" / �
PLUMBER'S NAME LICENSE# 3)g J SIGNATURE
MP ❑ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME �'� ' %-/I-7 s�t'� /� �"7 ADDRESS 3�� '�'`�'`'
CITY ��' ��'�'A/. ��6'` STATE /-771. ZIP TEL
Z G.G� TEL J���. �
FAX CELL 5a�-G EMAIL et 0 A...v,
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
I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Lj n- d
`` 06� CITY �r-����7�. ��/A MA DATE �� 2��� PERMIT#*f), I9'O 4'67
JOBSITE ADDRESS i'•fi 4/- 7`, �� OWNER'S NAME _�hi.9 d� '�
G
OWNER ADDRESS X5 /7-71;71.'i4 � ��� TELL-- 276- FAX
FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑-"'----
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES.I FLOORS-* c7 82
6�IA 1 3 4 5 69 10 11 1� 13 14
BOILER --I
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
F—
DRYER '
I
FIREPLACE '
FRYOLATOR ___-1
FURNACE
GENERATOR T 1
GRILLE RE C-E ! d E I-- i
INFRARED HEATER I1 I
LABORATORY COCKS r €
MAKEUP AIR UNIT AN 1. e 2a�9 i
OVEN i
POOL HEATER ;UmtDltvo r y. r�-T I
ROOM/SPACE HEATER i . _
ROOF TOP UNIT
TEST ...
UNIT HEATER
UNVENTED ROOM HEATER 1
WATER HEATER ✓�
OTHER
II
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES, NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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
I
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
t
•, CHECK ONE ONLY: OWNER ❑ AGENT ❑
` SIGNATURE OF OWNER OR AGENT j
:: I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to th my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compncith ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�
LI.! /
PLUMBER-GASFITIER NAME LICENSE# '7.5 SIGNATURE
MP ❑ MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# I
COMPANY NAME.4.6'Pi'" 4d.�.4S �J.Giri`f+ ADDRESS `9-y��r
CITY ti'e'5-# 444d' 7'7164'42' STATE /7-1062 ZIP 6 Z 't d.' TEL •- ' -3 .-V.
‘?/. .
FAX CELL `-21� -3(1-'4 � EMAIL FeAr,41rfj-i eGett.4.,l -C.9,1.4
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