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HomeMy WebLinkAboutBLDP&G-18-003747 • • MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK - P `, , cI1Y �� Q��rnoui ,^1 I MA DATE /Z-2/j 1-7 1 PERMIT# P ten-0 y,.,F JOBSITE ADDRESS �r 1 Tc C,C'a r I OWNERS NAME INTITa�j M_ + �s ' p OWNER ADDRESS \/ C r- C`A r I TEL b Lb- 5 FAX MEM . TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ® RESIDENTIAL PRINT ' CLEARLY NEW:❑ • RENOVATION:❑ REPLACEMENT:❑ :PLANS SUBMITTED: YES© NOD FIXTURES 1 FLOOR • gu0©© 4 5 s 7 sin -10 En 12 13 14• BATHTUB • Mt ll! lii ll !IMIWICIMI�u lllt!111hi CROSS CONNECTION DEVICEI�lll> I�! I ? I�I111 . DEDICATED SPECIAL-WASTE SYSTEM ; II 'I�IIIIIIIIIIIi! !IIIJIh�i . DEDICATED GASIOIUSAND SYSTEM illMi`! illl .!! i !! ILIK !IgIlmmorni' • DEDICATED GREASE SYSTEMh'�! I :I�IiII�:I�'�I�.III�! DEDICA t h U GRAY WATER SYSTEM MINICIO1.111111111111,1iMMEiMUISMAIM i li INIMIN' . .».11.201 :+, ______�__ ; !i I iM I1 C1111.11 I lI__ - • II�Ii�li�li� • DISHWASHER • 1nt111 — I l l! I III L INIIII DRINKING FOUNTAIN !tll!tlnili, I11111MI!iIIlilill • FOOD DISPOSER • IMMIKItal it 11 lll111.I it �J u Il ii li l FLOOR/AREA DRAIN JIIIIRIAMINVIMILM. >s�l � INTERCEPTOR(INTERIOR) ill l ! 111.11i�1'MI�C�IiCllilf KITCHEN SINK • :I i i i�� I i LW Win; LAVATORY 111=01011111.11111011MAIMINEFIWIIMI ROOF DRAIN II !MIM MAW il111:ICll OM OW SHOWER STALL )_—__ ..Ii111II�1��il� l;�l=ll SERVICE/MOP SINK I I III PUU • !i l it l i li llWl•11u 1 ' TOILET M IM.i i l l I ll_l�J1111 MIN IMF MM '. URINAL . . . �lllilVlilll ���llili�lit WASHING MACHINE CONNECTION .111111.11.1M111.01.11MiliniI�ii�JN�Vill� WATER HEATER All TYPES . wag l 1. _ 1 IMMIX iiim.williinumnim l l WATER PIPING ;l`I 11 a Ii li li I C II11 01iimil! iimt OTHER `l Jl>•111.1• I 11 u l liM--_!Il:!i !l Ali ----- ---- it !I II ILIEMi it—I - MIWIIMliMIRM INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent Which meets the requirements of MMGL 01.142. YES U' NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • • LIABILITY INSURANCE POJCY 51 OTHER TYPE OF INDEMNITY D BOND❑ • -✓ ✓] y OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 'V() 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 t hereby certify that an of the details and information i have submitted or entered regarding this application are true an, « to the• �; /. owledge • and that all plumbing work and'rrsstaliatlons performed under the permit issued for this application will be in cornpli. Pertinent y of the • Massa�seLs State Plumbing Code and Chapter 142 of the General Laws. .``� �� PLUMBER'S NAME N'NC. 1P_ C C 9 YTh 'LICENSE# I�?a�(�I S1GNA - 1JP,1 JP • • CORPORAIIONQ- {\`F IPARTNERSHIP❑# ILLC❑ - . COMPANY NAME rerrtrSXcC(ADDRESS •77(A l).[u-- �l I� CC7�2� - crrY ice, r:e.0 I STATE mirA as O2b t • ( TEL L. �R� q-102. ( • • FAX 15%c 4106 CELL CZ 2 Ic)t.za_tsEi� � (�+ (�r1r aU c_OrYTh s. t to . teEecY.wive tt n®rYm calm an 1rsP m e forxtfe prows=seta code.cwhvet3¢vsp tc las rmmirahie gem(hd 02/ilate Asair ssasae supnn a prrmees-a w hidh l mrtznq m of tie 'manse et tin codefinseh ma4estia=tore cow-male weir,dangerous re halarelma,the treaeoms k nutheitedm mr=the stz=o-penis saresomble tines mhapC cm pm-Form the duties Tm?osidMThb fie. pra9dr3 Sh's[Ensue 3tth�ue or premiers be oesspied that resdarenk he prams.'to Ile=Fat and waymesa:ai suchencose w premises k uresagned,thebenne=sh.s.1 fc==Ire s tameable effort to locate the owner or a c^peson ha`,dharseorhcor¢m1 pethpstrpprpre or ptrsnisrs and Tree entry.E entry is rdtmsi.the haprstrsiall hovere'Sur2mtla.rerrsetoo pmvhded by Few toseem envy. • - The Commonwealth of Mas..Tackusetts . at "- figD. - -_ - - eparbne zt of IndustrialAccidentr - • = 1_c - o-- ess Street,-SrdfP 100 - - , a li!, ci . . Boston,MA 02114-2017 • .'` ;=sue^ svwrv_mass goo/diet ' - Workers'Compensation Insurance Affidavit B ildersfContractarslilectricians/Phunbert_ - . " TO BE FTLED WIT(THE FATTING AUTHORITY_ • • • Applicant Information ,� Please Print Leerily Name(Bnsmt f I' l'e.Ll � �C►�' QLJC Y LP-k� 1 . • . - Address: 2 2-CA" Lh i V'Y Ist.- rez, . - . City/stateJZip: I c _Y X 026O1 Phone#: - 31 3 ` Q—tO Z. • . • - • . - Are puu an employer?C1 eck the appropriate tar Type of project l . 1.0 I am a employer wilt! 'employees(fail malorpart-time)- - 7.•Q New c em:ruction • 2.QIama snit propiietororpartnershipandbaveinoempiay cswo±ing for mein .$. QRr_mod Ting • .. • • any capacky.Cad wo3o=s'comp..insaaace,cyuiiai) • . • 3�I am abomeowne:doing aIlwo±mysr3 n3-a f INo ws•ri ms�a my. exzgimsd.)t 9 Q DemDlihon • • 4_0 I am abc wner and will be hiring c®contractors to du all week many yw in ty.I w . 10 El Braidingaddition • • ensore drat all contact=cif=ban wins'compeostaion izeszoan=orate sole • 11-QR1rr-trirjlupeLLSoradditions proprietors w nuo employees L2QPlomhmSrepairs or adcliticmc - 5.0lama general contractor andIhavehualthesabcontradna&sirdcmticat>nchedsbert 1.3.111R6bfn - : '. These sub-cratmctorsbaveemloye s=dimeundone cop. _. • t ti we area corporation and its affcsshave�cisedflan len of erect om perMGi.c.. - 14.[] •Ot rr - 152,41(4).Ilia we have Da r oployeez[No!cakes'WON.ias®ee n goired_] . • • 'Any anoinant that arrl ab=#1 must also fin out the setionbdow showing$ds woaia'ccarpmsntion policy infoaznotian 1"Einmeownccs who so oait this affidavit banding they am doing all wet&and thenllic.e outside mast submit a new affidavit ins rr•,+irig sock " - that clerk this box.mast attached an adaatiacal sheet showing the name of the sob-oont a too and slate wheder or not those evirties have torty)loyees If the have employees,they mast provide then.woes s'comp.po}cy mmabm '- . . I am an employer that is previa:ppm-kes'compensation insurance for my employes Below is thepolicy and jobsite information. , /' : . Insurance Company Name •� - ar'es and- C�r� • •• Policy#or Self-ins.Lie-#:11 X.f.,_:. 11?520 2C 1 1-A - • ExPiratiou Datt -4 6 • Job Site Address ( ty/Statelzip: - • • Attach a copy4i the workers'c omprnsation policy declaration page(showing the policy number and expiration date). . Fas�e to secure coverage as tcc fui.i.ccl under MCA,c.152,§25A is a ri i*nmal viola#ian punishable by a fine up to$1,500.00 and/or one-year meat,as well as civil penalties in the fog of a STOP WORK ORDER and a fine of up to$250.00 a - day against the violator.A copy statement may be forwarded to the Office of Investigations of the DIA for insurance e • coverage vt=ification._ -- . I do:hereby cerfibi wider Delp ofperj�that the unformaSrin provided above is hue and correct . - • Si Date • Phone#: - . Official use only. Do•not wry in this area,to be completed by city or town offu-ia - - .Cry or Towm ' Permit/License# Issuing Authority(circle one): - - • L Board of Health 2_Bm"tsfing Department 3.CSdp/Town Clerk 4.Hectrical Inspector.5.Plumbing Inspector . • • , 6.Other - - Contact Person: - • Phone#: - - - -' '' I ASSA.CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Mitt_gH CITY Op' Mr, DATE IZ 2LI PERMIT# JOBSITE ADDRESS %( bY.Nal T c C r OWNERS NAME 0..hiri( ', Lorirn GOWNER ADDRESS %ct i Y n Cr- 4 ,t FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS—* BSM 1 ? 3 1 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR. Uv _ _ _ GRILLE n i INFRARED HEATER I LABORATORY COCKS MAKEUP AIR UNIT OVEN 10 i l POOL HEATER ROOM I SPACE HEATER. ��1 ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER I WATER HEATER X OTHER 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YETI NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X 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 r•, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and urate to t est of owledge \� and that all plumbing work and installations performed under the permit issued for this application will be in compile . ith all Pe ' ent pr of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 PLUMBER-GASFITTER NAME3 Gsa`srl LICENSE# ( SIGN RE MP o MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION PA F 31-1 l$ PARTNERSHIP❑I I# LLC 0#1: I COMPANY NAME I�real�gX-I4-rrr C�YC, ADDRESS 229 1,i -e U- CITY lDre.t��R5►��r STATE IV.‘, ZIP 0� 1 TEL, l ¢-O XU - q 10z $ 4 FAX 3 1-06 CELL 3•2OS 3 EMAIL U` 4L ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTEq '(es No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT I PLAN REVIEW NOTES