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HomeMy WebLinkAboutBLDP&G-19-003608 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK U ,CITY y 1 V1m�' MA DATE L)le-1 i t PERMIT#/)LflP ? O0 fi Az JOBSITE ADDRESS csI C fr..1\ .t L Z ock 1 /, 0 - OWNER'S NAME 1 v/O ALic/.v POWNER ADDRESS .5i/fl E. TEL 56 J -3t2 -CCSy FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL HI PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:f PLANS SUBMI I I ED: YES❑ NO FIXTURES 7 FLOOR—F BSlv1 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 I ROOF DRAIN SHOWER STALL I SERVICE I MOP SINK TOILET I URINAL 1 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 t 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 0 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 co co Hance with all Pertinent provision of the Massachusetts State Plumbing Coda:and Chapterl_42iofthe General Laws. ��i • ( I 1 d I-f,--. SIGNATURE PLUMBER'S NAME 4-39fc ��(� LICENSE* ['EL JP❑` COWL-ORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME 1 - - 6 ADDRESS 3 dY 3 70 CITY 02i✓I©rfA�}l/2! — STATE A1— ZIP 0 2-G7, O37a TEL .-Gf- 3(� ULSY FAX / CELL EMAIL 61 CI S y 4 Q-60. Ai EGA41 7-."Fr • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 14. CITY tAira.wkc ,i 1 MA DATE I Z 1-2-I I F PER MIT i lit•OPle?VC1_360e JOBSITE ADDRESS At. to h t TE goG k P yr, OWNERS NAME D1 kit D t OWNER ADDRESS TEL Ca-34.2 6 y FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑D PLANS SUBMITTED: YES❑ NO APPLIANCES T FLOORS-- BSA 1 2 3 4 5 6 7 8 9 10 'I11 12 '13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER I LABORATORY COCKS —~ • I MAKEUP AIR UNIT OVEN POOL HEATER • ROOM I 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 t 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 ❑ • 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 comp• nce with inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the nsral Laws.�} uv PLUMBER-GASFITTER NAME ' LICENSE# pip el 171-- SIGNATURE MP ZI MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME _- -___ ADDRESS Zex 7‘i CITY ,4lwlQJT14 p021 STATE Mu-. ZIP 6 2_C.7r-0370 TEL S-a - 36 GGS G FAX CELL EMAIL(ceS 442 Q MSGiivc N