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HomeMy WebLinkAboutBLDP&G-18-004308 , 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i — CITY Y f n ov* F LM - a - I PERMIT# iQ'/�''��r � —� MA DATE JOBSITE ADDRESS 1-73 Silver l 'rf LA-Ae OWNER'S NAME �bb LOB �s`v POWNER ADDRESS 173 S I I ti Lorne TELCc1)Sag-aSis FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR--I Elul 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM 1 DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _ _ _ _ INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY • ROOF DRAIN c - '_; - D SHOWER STALL �,f�" SERVICE I MDP SINK i(„'Y q , 4TOILET i Ai bin 1 URINAL WASHING MACHINE CONNECTION , SU;; i)iN( nr"PARYeWNT WATER HEATER ALL TYPES 4 By 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 Ilig., NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE 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 c Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1�-t 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 complia with erfinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME 6eE t'otY Se re LICENSE#a4'71 iI . GNATURE MP fl JP [] CORPORATION El# PARTNERSHIP❑.# LLC❑# COMPANY NAME ‘Ci t o ei ce tc ?f�, 41,/7 6 ce r y c c.e. ADDRESS qt C eK l r 9 ece Lh ne CITY eth l Oho" STATE Ifil A ZIP 4-4 3 TEL\'� ��g / y FAX CELLO°Q,,��®I '(3Cf EMAIL reic't�c�� @.)i400.cor, V ff C 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 PERMIT TO PERFORM GAS FITTING WORK _IMF 7s i*LICIT( ?1'� � MA DATE FERIA IT f-a #77' 7 11( JOBSITE ADDRESS 113 CI'Lie C I taT Lh-c OWNERS NAME GOWNER ADDRESS I,3 S' ("el Cd-Sttale TE(S30—O cII FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL INI PRINT CLEARLY Y NEW: ❑ RENOVATION: ❑ REPLACEMENT: © PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 'I'I 12 13 I 14 BOILER BOOSTER j CONVERSION BURNER COOK STOVE C t DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR. GRILLE I ! INFRARED HEATER. 1 LABORATORY COCKS —� j MAKEUP AIR UNIT I OVEN i POOL HEATER .sue 1 ROOM I SPACE HEATER . - , ROOF TOP UNIT TEST ... . .. .__ . . . . . . ._ ...._ -_... .. . °at'I .._ UNIT HEATER 49 L0 UNVENTED ROOM HEATER Nfik WATER HEATER I p`, TMti OTHER 4 LU‘t4r� —t \r...13`1. I 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IlfGL. Ch.142 YES IZ9 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY fig 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. i 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 the best of my knowledge `k- and that all plumbing work and installations performed under the permit issued for this application will be in compli ith all Pertinent provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a '`b PLUMBER-GASFITTER NAME or,/..,1i c`� LICENSE# ao'c-f SIGNATURE MP ❑ MGF❑ JP [I JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP El# LLC❑# I / COMPANY NAME t7c'S,y re(ce Pt,-,no,r-IC cc'tiaC ADDRESS 41 s'f C,"`'-e- Lv'C I CITY Lk' YIM'"• STATE 'Yr`"A ZIP Oa6-7 3 TEL �SrcJ '13 LiFAY. CELLkr i"H EMAIL CtaC'^'- t- YE'6-vsn— i , . i s i 1 1 G, 0 4 ' 0 I �d 1 L) At I O, I I i 1 4 0 LU C) °-Lu 4 i N = h- M�— �a ! C ca Of I Z a >- L GA Q Pk L> r M. CI- 1 I- r C) Z 1 0 w I r 1 4 0 0 0 g i 1 1