HomeMy WebLinkAboutBLDP&G-17-1631 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—""�— CITY /2.--vkM. (fat, MA DATE 4 f,r--_ f-fa PERMIT# /%/ l7-0d/ ✓?(
JOBSITE ADDRESS 2�A J ICv OWNERS NAMEe" 2,i j I / L f, ��I De, L
POWNER ADDRESS '44- A._ 6 TEL 5ePr FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ 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
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL 430_`
WASHING MACHINE CONNECTION _ C)
WATER HEATER ALL TYPES f
WATER PIPING
OTHER k"
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 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
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 P rtinent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIG�IAA� R
MP❑ JP❑ CORPORATION ❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME GA'-'la• , 5 l n/GADDRESS
CITY ' 1 STATE ZIP €7Z.e _3 TEL <e), rS'
FAX CELL EMAIL tZ,VID& a IVAAVVI9
,1/'1"'ia 1A7.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE PERMIT#/Jtr-/2/l'f 7 00 /6y,
JOBSITE ADDRESS fi1 /p ip OWNER'S NAME L� f/i.
OWNER ADDRESS .-( cQ 36 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENIIAL-ii4,
PRINT
CLEARLY
3Y NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—I. BSM 1 2 3 4 5 5 7 s 9 10 I'I 12 '13 j 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 0�
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.C1h.142 Yalt 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.
�.d 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 Perti visi of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME c:76- -i6 6/11/1" � �Pd- `LICENSE# /�j�"" SIGNATURE
MP❑ MGF❑ JP.a JGF❑ LPG! ❑ CORPORATION ❑# PARTNERSHIP 7# LLC❑#
COMPANY NAME ADDRESSI' >'a
CITY > c12 � ��f{7 STATE 7¢ ZIP e7Z6-7-__,F TEL
FAX CELL EMAIL