HomeMy WebLinkAboutBLDP&G-16-004446 `,s, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- .sir r J�.:v MY �` MA DATE 1/I (, PERMIT# P-A; owg1%'
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JOBSITE ADDRESS / ° OWNER'S NAME ('j r, L._ c p
P OWNER ADDRESS TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL Cl/
PRINT
CLEARLY NEW:ElRENOVATION:ElREPLACEMENT:LEI PLANS SUBMITTED: YES El NO El
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)
KITCHEN SINK
LAVATORY _
ROOF DRAIN
SHOWER STALL _
SERVICE/MOP SINK
TOILET
URINAL _ -
WASHING MACHINE CONNECTION
WA I at HEATER ALL TYPES I
WATER PIPING
OTHER 7
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YE NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE 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 El 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 wil be in with all Pertinent - of the
Massachusetts State Pkanbimg Code and Chapter 142 of the General taws_
PLUMBS 'S NAMES Inc<\ill) LICENSE#I Scl`13 IGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIP❑# LLC El#
COMPANY NAME C C 1l 1 " ADDRESS 1 6 1 p‘,,s1.4,1.„,„. C„
CITY c r. 1,.i m t\-• STATE'i%t ZIP 0)-S 63 TEL S-v 1-- 3 t 7 v S S.2 S
FAX CELL EMAIL
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`" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
kNi.; CITY j, ,c.�'`� MA DATE /' PERMIT# /91-12r/li— `/YLK
JOBSITE ADDRESS ;.1 11 I (t, W4J OWNER'S NAME M r 1..— ( c
G OWNER ADDRESS TEL FAX
/
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:d PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE ,
DIRECT VENT HEATER
DRYER _
FIREPLACE _
FRYOLATOR
FURNACE _
GENERATOR
GRILLE
INFRARED HEATER _
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
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 MGL Ch.142 YES NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIU1Y 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER El AGENT El
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 compliance with all Pertinent provis of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBS GASFI1TER NAME Tif... [LC} r) LICENSE# 1 S 9 1 3 ATURE
MP MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP
S�❑11# LLC❑#
COMPANY NAME: G C M P ADDRESS I b I P'^'L',--t Jt r
CITY S./t•! Wii}N STATE AA ZIP O)St3 TEL ,5-0g'` 3I7' SSaS
FAX CELL EMAIL
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