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Home My WebLink AboutBLDP&G-17-006043 • s_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , CITY VP C N�,) C-1n MA DATE WI 1 7 PERMIT# /117`Ou 6; 3 JOBSITE ADDRESS OS ) S pc ,r'e( L.g, N OWNER'S NAME (a)SF'rlbl/1 OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,- PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:IT`' PLANS SUBMITTED: YES❑ NO❑ 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 . ';i1i' fn SHOWER STALL SERVICE/MOP SINK '}r TOILET I 0 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 VI NO ❑ 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 comp' nce w h all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME Cy 1,lt a - ETje C. f LICENSE# Idc( d SIGNATURE MP JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME (VI I?- (3) -1"?,I P ADDRESS 3 III P:r P s CITY C S r i e STATE M R ZIP b g-L a TEL C6 a 7)/ " Og 3 6 FAX CELL EMAIL e/! o 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 PERMIT TO PERFORM GAS FITTING 7 WORK -rs /FYI r /��'/�i�/7-�/�c�y1 e 64 CITY \VP�/��au�tn MA DATE P_RMIT. JOBSITE ADDRESS c d0 L p AP OWNER'S NAME PoSe-i,�i i i OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL. j PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:, PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS H --4 65M 1 2 3 4 5 fi ? ° 9 10 'I'I 12 'I3 1 BOILER —1 BOOSTER CONVERSION BURNER ' COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR. _J GRILLE p i INFRARED HEATER M''Y "e LABORATORY COCKS MAKEUP AIR UNIT t53c. 6O42/ OVEN POOL HEATER ROOM/SPACE HEATER I ROOF TOP UNIT TEST - _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER ( ( OTHER _ I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ ND ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE.APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY yn OTHER TYPE INDEMNITY ❑ BOND ❑ LOWNER'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 complian with Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LEI PLUMBER-GASFITTER NAME 6-5: t i'A"" I`'1250r`i► LICENSE# / Sid. / SIGNATURE MP [ MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME (YI R /L- 4 - Pie e ADDRESS 34/ P,>t S 1 CITY Fn ��"� \ a STATE (Y1 ZIP oa(.93 a TEL cthi >76 3.� FAX CELL EMAIL me- pk1 L 11 Y 71 I7T • , 1 I C.) glt Gr, I 4' I I I i I I i I 1 G ,� I �o I co F- Gr1 0 I F I .. CFIcr> cr o a LLI 1 us w Q Q, < IA.. co id 1 LO 0 z Z I w co 1 4 i n 1