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HomeMy WebLinkAboutBLDP&G-19-003242 • �•. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '1 • -4 CITY ' As: oJ6 k MA DATE i i(D C/e , PERMIT#k /9-h ©U, JOBSITE ADDRESS • ) 1 . OWNER'S NAME 0 W C;e' Dti�b 1' OWNER ADDRESS . .. TEL . . . . ... FAX... .. .. . TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ,. RESIDENTIAL: PRINT . CLEARLY NEW: . _ RENOVATION: , REPLACEMENT:( PLANS SUBMITTED: YES NO .i.if>C*l,.Wvaa V i r.16.9e1. , mee.,e , n +. v . .v y u .t.! s. ii #V rr BATHTUB • _. .. CROSS CONNECTION DEVICE - . . • ... . DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAWOIUSAND SYSTEM a..... -t a....__ {.. .. .. . - r DEDICATED GREASE SYSTEM . .. r �.. DEDICATED D GRAY WATER SYSTEM f DEDICATED WATER RECYCLE SYSTEM :...: .. .. . :. DRINKING FOUNTAIN I FOOD DISPOSER _ FLOOR/AREA DRAIN _... �.._ ._ ... . INTERCEPTOR(INTERIOR) _ _ u..... ..,....^ KITCHEN SINK LAVATORY 1 ROOF DRAIN , V66V774r11 GO IJRti.i i.SERVICE/MOP SINK _ . ..._ . _.... ...s .. .,. _. ..... URINAL . WASHING MAGMINE CONNECTION r. _ �. .a,.,.-,..•.., . ... . >... ._ . ._'r... WATER HEATER ALL TYPES _. WATER PIPING �. r OTHER 4:e• i i INSURANCE COVERAGE:I have a cuneut jfabt ttr Ineurencs poky or ita substantial equivalent which meets the requirements of MOL Ch.142. YES 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 dyes not have the insurance coverage required by Chapter 142 of the Massachusetts General Lawn and that my signature on this permit application wives this requirement CHECK ONE ONLY: OWNER AGENT F.',': SIGNATURE OF OWNER OR AGENT I hereby codify that all of the details a llnformation I have submitted or entered regarding thie application are true and aocama of my kno $edge and that all plumbing work and installations performed under the permit Issued for this application wui be In t[fbnt p►vrrf of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAEVIE iM I LRO I LICENSE# 169§3 1 _ RE MP 0 JP CORPORATION _ .# PARTNERSHIP .Y# LLC # COMPANY NAME•CAPE COD MASTER PWMBERS,INC. t ADDRESS. 70 CRANBERRY HWY PA.BoX 758 #, GARE • ISTATE .. t CITY SAMOZIP -_ 8 -.1_.. .__. _ — . .... .. . . ... MA 0OM �..,.� 7EL'St18..317-66Zb . _ . . CAV 1^CI 1 r<AAAII I I ~� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK sI1- CITY MA DATES�I z,6I Y PERMIT# P ''®Dye r €QV JOBSITE AppRESS' r l q OWNER'S NAME ,,� _..�._.._.�._.,__._..,' GOWNER ADDRESS TEL.__-w-�.._...._...._..� _ 'FF`AxX TYPE OR OCCUPANCY TYPE COMMERCIAL---1 EDUCATIONAL 1 "'. RESIDENTIAL Y PRINT CLEARLY NEW: RENOVATION „ REPLACEMENT: PLANS SUBMITTED: YES NOL APPLIANCES 1 FLOORS-0 BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14 BOILER t_. �. BOOSTER 1 CONVERSION BURNER ... ._`_ . .�._ _1. '. __,L ,. .__. R_ ' ". f COOK STOVE i DIRECT VENT HEATER DRYER -. . �_ . 111111 FIREPLACE ` _. IBM _,. FRYOLATOR __.__ �.._` _ a,rt. FURNACE �:. ,. ..GENERATOR MN 1111111111111M1 VIII Mill 111111NO IMI Urn GRILLE .--._._ INFRARED HEATER _ .' �, ,, % �... . ..._�• ..: LABORATORY COCKS MAKEUP AIR UNIT OVEN , . ,41111111111111111.111111111111 4,m POOL HEATER ROOM/SPACE HEATER , .._ �d. ' i, ROOF TOP UNIT i.. k ._, TEST UNIT HEATER P ' UNVENTED ROOM HEATER WATER HEATER �., ..,. OTHER �. .__ 1 ,r 1«. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 64- NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY `>, OTHER TYPE INDEMNITY BOND I 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 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 Peril ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME T t M AC 0 `� LICENSE#;15Cjc�3 T E MP MGF. JP p�, JGF:. LPGI CORPORATION X# PARTNERSHIP '1/ LLC # i COMPANY NAME: ADDRESS q CITY k a� CSC, Q, STATE i AA i ZIP!p? l _�.. TEL 31` 55 2 r___.._.__.-_. FAX y CELLS �z .___ . EMAIL'(`jYYti&e_ vecod Cl l- i Q.mom,�Can,_. _._ .. Viz.