HomeMy WebLinkAboutBLDP&G-18-000045 `V , .....---
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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lii CITY 4 YAW try t'f' MA DATE 7/$1 O (jI / PERMIT#IJLo-Jf4-O `/5—
�� JOBSITE ADDRESS 1 LAIN UG I\D OWNER'S NAME4Ill Q <:y aaLiCa4,I
POWNER ADDRESS S .Q_ TELO& J 6l—(573F
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL, '3c\y l '
PRINT �O n�—
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:KL PLANS SUBMITTED: YES ❑ NO❑
FIXTURES 7. 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
T
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY _
ROOF DRAIN _ _
SHOWER STALL
SERVICE/MOP SINK 1 (I :
TOILET
URINAL -
WASHING MACHINE CONNECTION t
�C
' WATER HEATER ALL TYPES ` 9
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❑ 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 W,�I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Ma sach - s that my si nature on this permit application waives this requirement.
"milb. Ilk CHECK ONE ONLY: OWNER ❑ AGENT ❑
(----- 1ATURE OF OWNER R AGENT
I hereby certify that: I 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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE# ?? 5--- . SIGNATURE
MP n JP❑�� �—) CORPORATION❑# PARTNERSHIP❑.# f ^�LC❑#
COMPANY NAME J 1✓r] - I r Qwee ADDRESS R J Cl se.,CGvr2 I ‘ )U. 1 virbt
CITY w• l /0/2t#►'tlh STATE f)'7 ZIP O 6 73 TEL 6—U S''6 '"1/Z)
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FAX CELL EMAIL c.S 1 Tle4 fq,'(IY?'1") )J 1
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
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, ,.._:„.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r J CITY vt di' #14OP-/ga`;�:6.���,.s � YPI rLWI '- � MA�DATE PERMIT.r
�,. JOBSITE ADDRESS is- tie/y v 1 > q I Rl ev LcI 6/
OWNERS NAME d� / � f3
OWNER ADDRESS 3(4)11.e TELV g 3(a/ -O 7 Zip
TYPE �OY'r1c— \
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL SOS ))y-
lU ^S
CLEARLYNEW:❑ RENOVATION: ❑ REPLACEMENT:, I PLANS SUBMITTED: YES❑ NO❑ 1
l
APPLIANCES.I FLOORS-' BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 I
BOILER
BOOSTER _ I
I
CONVERSION BURNER
COOK STOVE `
DIRECT VENT HEATER __i
1
DRYER
i
FIREPLACE '
FRYOLATOR
FURNACE
GENERATOR I
GRILLE i
INFRARED HEATER
LABORATORY COCKS I
MAKEUP AIR UNIT I
OVEN i
POOL HEATER 1
ROOM!SPACE HEATER 1
ROOF TOP UNIT '_) ;-i '/
TEST
UNIT HEATER
1 4 `.J�-'
LINVENTED ROOD! HEATER
WATER HEATER bZ I
OTHER
I
I 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.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 ❑ I
OWNER'S INSURANCE WAIV • I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the I
Peas•achusetts Gen • . ,, hat my signatur nnf•hi?ermit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT IIIli
SIG AT . OF OWNER 0 , GENT j
I hereby certify that all he 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 provision of the
Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
Q.)
PLUMBER-GASFITTER NAME LICENSE#(,2( SIGNATURE
MP MGF❑ JP K JGF❑ LPGIJ:;.---) CORPORATION❑#F PARTNERSHIP❑# �� LLC❑# �
COMPANY NAME -3e 1,)" fZ ADDRESS S CJ f 1ZC[U 'v /Y d
CITY o ,,,,J,,J✓`0()f`1-1,-) STATE ZIP Cb / TEL`� �1-V(� y-�/CJ:—
FAX CELL EMAIL____X
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NG'I'E4
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# /t)( /v 5
PLAN REVIEW NOTES
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