HomeMy WebLinkAboutPlb/Gas Water Heater 8/17 - no permit # G . A 4
•• _ M ASSACHUSETTS UNIFORM , "P CA•N *IR P ' T• PE 1N1 WORK
�` :p,',���, s CITY %� C—!� Y� V [17 MA DATE _ig: 2 PERMIT tt
tk.� JOBSITE ADDRESS e> / OWNER'S NAME �`
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GOWNER ADDRESS FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—} ssM 1 2 3 1 5 _ 6 7 8 9 _ 10 '111 12 '13 11
BOILER _ ----I
BOOSTER _______1
CONVERSION BURNER,
COOK STOVE --;
DIRECT VENT HEATER -
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR t. '_A
GRILLE .
' INFRARED HEATER I
LABORATORY COCKS
` 1
MAKEUP AIR UNIT (g_OVEN , } L. _,, e, - ,
POOL HEATER
ROOM I SPACE HEATER '
ROOF TOP UNIT
TEST - .
UNIT HEATER
UNVENTED ROOM HEATER i f
WATER HEATER /
OTHER /
INSURANCE COVERAGE
I have a current liability insurance•poolicy or its substantial equivalent whic Bets the requirements of MGL.Ch.142 YES 140
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE B ECKING 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.
i. CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 accu the best of my knowledge
•; and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER N ME LICENSE V
SGNATURE
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MP 6hF P F GI ❑ CORPORATIO ❑# ✓✓PARTNERSHIP❑# LLC
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MPANY NAME �l >' 1 V / '14- ADDRESS ;/ ASV I Wes' Y
CITY Y 6 it " 4 STATE_ZIP_____a2_ZZL TEL, D
FAX CELL EMAIL
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f. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 7 MA DATE PERMIT#
JOBSITE ADDRESS OW J OW R'S NAME\/L — ff yAJ
•
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1. FLOOR— BSM 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
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
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING _ _
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its s antial equivalent which meets the requirements of MGL Ch. 142. YES NO ❑
IF YOU CHECKED YES, PLEASE INDICATE TH YPE 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 ac 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 7? 1. • SIGNATURE
MP CORP RATION # PARTNERSHIP 0# LLC❑#
COMPANY NAME / /6W—I I ADDRESS Aff&HIWKI �'— —
CITY YP9,e L O V a�' STATE A4I 1 ZIP TEL c ,5qc? .
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES