HomeMy WebLinkAboutBLDP&G-18-003837 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY/TOWN y' %i „'j MA DATE / /5/ /4 PERMIT#
JOBSITE ADDRESS 300 gvtk /Sc,a-w➢ 2U 9C OWNER'S NAME 1x+- y /VA LL Qct/- ;
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z 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 r l
URINAL U
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 ENO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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 tile best of m knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with atrPffiitinent rovisio of the
Massachusetts State Plumbing Code and Cpter 142 of the General Laws.
PLUMBER'S NAME 1 / 1 c� `` /�✓
��///V/4 LICENSE# //,> 2 SIGNAT RE
MP 2' JP❑ CORPORATION❑# PARTNERSHIP El# LLC❑#
COMPANY NAME / L" /(. /-/ 2,it- ADDRESS % �% 2)4,/L G S/
CITY A') /Z C'h/,} �e'1— STATE //I//a ZIP 6' 2-2-6;j' / TEL 1 7 J YZ 3
FAX CELL EMAIL l.S f c/ 24/37 A2; 7
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c.
=_1 i_- CITY (/,Q/ /iJ /l� MA DATE /3// PERMIT#/4/-V-/I'dvi 7
.may
JOBSITE ADDRESS 3 ec) /.4) 7c OWNER'S NAME TY-4cl p: s�
GOWNER ADDRESS TEL y - y y7 •2 3 'SFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Eit
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: [ 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 I SPACE HEATER
ROOF TOP UNIT = �,. , 4L (JV
/„Q� D
TEST lyd
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 O'IVO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a / 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 acurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian with�!I Pe ' ent provision the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�
PLUMBER-GASFITTER NAME LICENSE# //3 2. SIGNATURE
MP Er MGF❑ JP❑ JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME /✓/►j V/ �� �'� ��-- ADDRESS
t 6 ?
CITY b,C 4,::5 /et, STATE //26 ZIP l ) TEL k 23 7 Z j
FAX CELL EMAIL
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