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HomeMy WebLinkAboutBLDP&G-19-02664 s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1-�_S� CA � p n D L - CITY ©VTR^ d' T�/` MA DATE /QQ0 3/ PERMIT(# n /" -1 -00R JOBSITE ADDRESS I q /ewer- aeCO® K... O1 OWNER'S NAME JcC1C Jct.) POWNER ADDRESS a1 ej4 I a+'VV cl -kr,...._ TEL7 7t/-3.53` 2'-1) FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR-4 B51v1 1 2 3 4 5 6 7 B 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 DEDICA I Hi WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ) LAVATORY I ROOF DRAIN s SHOWER STALL SERVICE/MOP SINK I TOILET URINAL • . WASHING MACHINE CONNECTION LL' I. WATER HEATER ALL TYPES +�� DEI+�aT ' WATER PIPING r OTHER ,r. _ __ _ INSURANCE COVERAGE: —/ I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ef NO 0 IF YOU CHECKED YES, PLEASE INDICATE TH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 14 of the i` 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 e 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. N PLUMBER'S NAME LICENSE# SIGNATURE . MP ❑ JP CORPORATION❑#R©Ofg_ PART HIP❑.# LLC❑# __cc'+ ! \ j COMPANY NAMS�ILI t 5 f Jrkhi►1 ScV it CN ' ADDRESS /t'S E-44e 4) e j / _S CITY ✓p u./S/ �� STATE ZIP ©a � 3 TEL 7 )� `7A -s'Y t.--t FAX CELL EMAIL / s 0 z z 0 U r1 rip z crfa o o a z ~ r o LLI y a. L o > f LU z 0 �` P- c., J n_ a_ Q � al H u co 0 0 U 0 o MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' 1��.��... 7s 116 /� Q ` J (� '` w►0 LAI\ MA DATE /0 v2 Vi n/ �6`�i�r CITY�c'c)�-vim Ytor / PERMIT# , JOBSITE ADDRESS 19 lower Vreelz, Rot OWNERS NAME J v GOWNER ADDRESS SOc1-/-L Youf;MVO-1-k. TEL77 r?5 ?FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PbT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:[� PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS--4 BEN 1 2 3 4 5 6 7 8 9 10 11 12 •I3 14. BOILER — I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR 1 —~ FURNACE - GENERATOR GRILLE I INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN Li 2E1V D i POOL HEATER • - `R 1 ROOM/SPACE HEATER ROOF TOP UNIT t. fl �'ll TEST -- , UNIT HEATER ; :''"'- _;A• : Ii UNVENTED ROOM HEATER a,w wlq t WATER HEATER ><1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES LeN0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGES?CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0•"-- 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 ray signature on this permit application waives this requirement. -, CHECK ONE ONLY: OWNER ❑ AGENT ❑ �e SIGNATURE OF OWNER OR AGENT i : I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac urate to the best of my knowledge `k- and that all plumbing work and installations performed under the permit issued for this application will be in co 4liance h all Pertinent provision of the ' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,� PLUMBER-GASFITTER NAME LICENSE# / SIGNATURE LC°MP ❑ MGF❑ JP kr JGF El LPG' El CORPORATION El# f383 IP 'TNERSHIP❑# LLC❑# I COMPANY NAMG>Ir41e*eve-if ki tA/ i v/PC-e S. ADDRESS /b E44-(o44/ Lei eve- CITY 1.;)r e 4,41 S/6'a— STATEt fk ZIP oa&31 TEL7,y-S 79 ••Sr?� FAX CELL EMAIL Ve ca- 1M L-sD