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HomeMy WebLinkAboutBLDP&G-25-634 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4 r M th)ir-1t `';sL�1�YG tE MAP PARCEL MA DATE 777(IZ S IPERMIT# 1)e—'2s 4'3y JOBSITE ADDRESS Vz C A 2'-'(J .,, 7Lrji OWNER'S NAME //'}7t(1 f iCP OWNERADDRESS re'lTEL 7 7/- V/11FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO( FIXTURES 1 FLOOR—* BSM 6 7 8 9 10 12 13 14 BATHTUB I li W i i: CROSS CONNECTION DEVICE i DEDICATED SPECIAL WASTE SYSTEM i i II DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM WA DEDICATED GRAY WATER SYSTEM I i ,.( ! . „r., ._ I. II I DEDICATED WATER RECYCLE SYSTEM 1 _ ,i �„ ! ,, ; _ ',... DISHWASHER DRINKING FOUNTAIN i ' ,II; I 1 FOOD DISPOSER l! FLOOR/AREA DRAINI INTERCEPTOR(INTERIOR) i KITCHEN SINK j I ,. I LAVATORY ROOF DRAIN SHOWER STALL111' 111111 �SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES j ! 1.1.._. .. J� t, -I, . - n-., ?dam .� _ WATER PIPING ,� : OTHER lr r I i _ i , —.,. , ` ,._e . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES M NO (,W IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY © BOND EI 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 Q 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 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 provision of the Massachusetts State Plumbing C i e and Chapter 142 of the General Laws. PLUMBER'S NAME ► (I/c err ilit cJ (`1 i' ILICENSE# r 1 r/l SIGNATURE MPD JP'a— CORPORATION®# _ 'PARTNERSHIP©#I LLCLJ# ' COMPANY NAMEI' k(TIC 146 �� ADDRESS "37 `�— c'Ch 1,1 /4.A."11 CITY ��_�_ /////"j Gf /1 /11 5 7 STATE A/4- I ZIP 0 Z (., o / I TEL FAX 1 CELL EMAIL _ I • C , a'-t\c-1-- i,i G 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 PERMIT TO PERFORM GAS FITTING WORK CITY v MA DATE Z PERMIT# p-ZS -lP3y JOBSITE ADDRESS 4 .tom e C i`f' OWNER'S NAM e r-- R GOWNER ADDRESS 7- TEL77 J / / FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL tz PRINT CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT. PLANS SUBMITTED: YES❑ NO[i APPLIANCES FLOORS-, BSM 1 2 3 4 5 6 7 g 9 10 13 1.4 BOILER - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR - FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT 4- OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT IR C 1 �. i TEST �.. IF UNIT HEATER UNVENTED ROOM HEATER "' / j j 20,J WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES R NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 141 OTHER TYPE INDEMNITY 0 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 submttted 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. % /7 7/ (� �- PLUMBER-GASFITTER NAME LICENSE# � �C l�SIGNATURE MP ❑ MGF❑ JP �Q JGF❑ LPGI CORPORATION❑# PARTNERSHIP❑4 tic❑# qq HiCOMPAN E "l C/3 rl "� ADDRESS S 7 I I�n l•'J d �`� CITY l . 7 / " ZIP //D L7/ `�/ Z v `�� � S STATE�/L7� � �lO � TEL )�7 � / Z FAX CELL EMAIL 517i1 927-• N1 cl t 495 /( ' 60 A.N. OA 2v- ' 3)-1 q - 't L(0 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: $ PERMIT# PLAN REVIEW NOTES DIVISION OF OCCUPATIONAL LICENSURE BOARD PLUMBERS AND GASFITTERS • ISSUES THE FOLLOWING LICENSE'' �. JOURNEYMAN PLUMBER • MICHAEL R MCBRIDE . . • 37 FRANKLIN AVE.. • • HYANNIS,.MA 02601-2603 :. I. • 'f 9fi8 I 45lt1/202fi 622478 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER • • • • • I