HomeMy WebLinkAboutBLDP&G-17-000507 1nft-1 z-iL i1 titi v1 /, -') f11-L-- -}1 s
MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT 0 PERFORM PLUMBING WORK
t=`TIF. CITY V�>---1(A MA DATE PERMIT# i",$- 1P")7 c 51.17
JOBSITE ADDRESS'5( I.0 26 vv cl r .5\OWNER'S NAME 7I 7_,:l.v-40( L{ 5
POWNER ADDRESS C ( vli-e" L L 9 0 I - tA/ L /7/ -5-1--CZ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: El REPLACEMENT:❑ PLANS SUBMITTED: YES El NO LI
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 _ _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 7f_
OTHER
i_. INSURANCE COVERAGE:
,J have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES (]
'' IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
`�' LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY El BOND El
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
I C�I Mtchusetts General Laws,and that my signature on this permit application waives this requirement.
it IJli
CHECK ONE ONLY: OWNER ❑ AGENT El
ift ?.
�`�' .�' 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 ail Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURES
MP❑ JP 13— 1) no 1 ' CORPORATION # PARTNERSHIP❑_# LLC❑#
COMPANY NAM ICP L )--- - ADDRESS 7 �c �
CITY 5-0b , CU STATE -ZIP 1.) . r TEL -72V VC) 7(
FAX CELL EMAIL 61--, /.�}�/�°_M (.11 L c...cc) ac:3^4/ &@'t
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
1
• MASSACHUSETTS UNIFORM APPLICATION FOR A P RMET T PERFORM GAS FITTING WORK
It� '%_cry 1 n
f'P J CITY :,.J� cA r (�/\ O MA DARE Z PERMIT# /3/-11 Liz-61D 501
JOBSITE ADDRESS 'l a6" 11 (, 2s £ \ OIhINER'S/NAME ( et/,1 -e L�
GOWNER ADDRESS C r e)wP t.E__ f(—U✓'h�--) �fEL 2 do FAX C i ! 5 Fr?
TYPE O r
PRINT OCCUPANCY TYPE COMMERCIAL �' EDUCATIONAL ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:CC.----/- PLANS SUBMITTED: YES❑ NO[g/;/
APPLIANCES 1 FLOORS-
6JO 1 2 3 4 5 6 7 3 9 10 'I'I 2 1 13 1 14 I
BOILER —_
BOOSTER I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
l
DRYER
FIREPLACE 1
FRYOLATOR _
FURNACE
GENERATOR.
GRILLE ■
INFRARED HEATER
LABOP,ATORY COCKS
MAKEUP AIR UNIT
OVEN 1
POOL HEATER
ROOM;SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER �r
WATER HEATER IIIII
OTHER
1
1
.
INISURANICE COVERAGE
ifs 4 have a cUrreilt liability insurance policy or its substantial equivalent which meets the requirements of MUIGL.Ch.142 YES �IQ Q
'u t I II QU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE Y CHECKING THE APPROPRIATE BOX BELOW
`�" LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
O ER'S€NtaURANCE WAIVER: I any aware that the licensee does not have the insurance coverage required by Chapter 142 of the
I
(„� F Nlas�acf� selks General Laws,and that my signature on this permit application waives this requirement.
L!J i I
M CHECK CNE ONLY: OWNER Q AGENdT Q
1frl .1 SIGNATURE OF OWNER OR AGENT j
I
thereby 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 Pertinent pr vision of the I
Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
N- -kPLUMBER-GASFITTER NAME (1(° ' LICENSE ` ' __- SIGNATURE
MP ❑ MGF Q JP�GF❑ LPGI Q C RPOR,ATION❑# Y"rd PARTNERSHIP❑# LLC Q# I
f P p t - /COMPANY NAME f\ k ADDRESS 6 CC! i J
CITY 5 (�(� (� STATE ZIP TEL) *Fld 7? Z Z 1
FAX CELL EMAIL /'r . fL`'S- ., 4
moil-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
'(es No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES