The URL can be used to link to this page

Home My WebLink AboutBLDP&G-18-005735 a° T d/. kkE MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY J It-g._ 0 V MA DATE z g PERMIT#bt`0P JOBSITE ADDRESS all✓ OWNERS NAME 6- 1 . ti-Axt OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR—F 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 1 AREA DRAIN INTERCEPTOR(INTERIOR) _ KITCHEN SINK • E. LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK • �'�� TOILET i-t- i URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER � � I INSURANCE COVERAGE: I have a current liability insurance policy or its substa equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 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 `t I hereby certify that all of the details and information I have submitted or entered regarding this application are true and curate 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 ' all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NA 0 Q F bvLO5 LICENSE# /5- q. /, SIGNATURE ERSHIIP .# LLC❑# MP JP❑ CORPORATION/�❑# PART ❑ COMPANY NAME /j- & )2T P tF1 I ADDRESS Z & T(10 v Vi CITY /pyZYocE1—i STATE Pi(if ZIP 026 6j 7 'S TEL FAX CELL EMAIL 'g J Z/0— 6� 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 CPS VAf .-K_ /26 -'›,'` 'MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT T PERFORM GAS FITTING WORK imtotep 61 ", ro'w CITY MA DATE `... �,s, PERMIT JOBSITE ADDRESS a&g. OWl LR'S NAME GOWNER ADDRESS TEL FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PFtINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES.I. FLOORS—I BEN 1 2 3 4 5 6 7 8 9 10 11 12 •13 16 BOILER _ -----1 BOOSTER j CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT AF'h ' fl OVEN 7 i POOL HEATER • ROOM I SPACE HEATER ---(::21-- CP ROOF TOP UNIT TEST _. . UNIT HEATER AT TED ROOMHEATER WATER HEATERER OTHER 1 _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ 1 • 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 .y CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 4-, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a urate 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 th all Pertinent provision of the 1 `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `1 PLUMBER-GASFITTER NAME pm-m/1--0---0e01/605ICENSE#/5 SIGNATURE MP ! J�C�F JP JGF PGI❑ CORPORATION❑4t PA.CFI ERSHIP❑# LLC❑#i COMPANY NAME 6PS4 g T P.1HADDRESS _ 6y f I '(141� J� CITY /4— iuI STATE " ` ZIP 02673 TEL '� FAX CELL EMAIL 368 366 J 9' z_leII- bum -_ I ` • I . I cr../ P 0 I 0 I f C) r1 I Gf, I 4 .--t I r. I 1 I I 4 «0 I � L I rrl 0 L 1 LLI N I F- U, rx us CO 4 -4 Q gli P a. Fw EL co Lf I rco C H 0 I I C I co I 4 i M IVI 0 I 0 i