HomeMy WebLinkAboutBLDP&G-23-11684 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: Ilk C W)141 MA DATE: l 5)21 PERMIT#RL t) Z 1 i t L.
Slt'JOBSITEADDRESS: 21 Ill 4: [c.m. t)r GOER'SNAME f/Q ex DtlGI7Af btL
GOWNER ADDRESS: 5c.Mtia.- TEL:50Z 3641 6504' FAX* /
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL Ly'
PRINT / —
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Li PLANS SUBMITTED:YES 0 NO I�'
APPLIANCES? FLOOR—. Berra 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER /
BOOSTER
%. CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER RECEIVED
ROOM/SPACE HEATER
`I ROOF TOP UNIT (it TEST $EP 0 5 ?023
UNIT HEATER
UNVENTED ROOM HEATER BUI_DINC UEPAR1MENT
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0
If you have checked na,please indicate the type of coveeraa9pby checking the appropriate box below.
LIABILITY INSURANCE POLICY L/1 OTHER TYPE INDEMNITY❑ BOND 0
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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and informationI have submitted(or entered)regarding this applcation are true and accurate to the best of my
Knowledge end that all plumbing work and installations performed under the penult issued for this applicatlo wl in c4' lJance with all Pertinent
provision of the Massachusetts State Plumbing Codeand Chapter 142 of the General Laws. �( f
PLUMBER/GASFITTERNAME: J.'1rI d2 Id i a�oa 5 LICENSE# I�yv, SIGNATURE
COMPANY NAME: J 1C Lk()S,g flubs ADDRESS: L( Ant tlls/ V
CITY: t,fvf^C�+LVY1 STATE 1.- zip 0261 I FAX:_
TEL.: CELL:I1Y 736 6529 EMAIL Jai I,(c-Terworlv3 6-C9t—Itl.cp
MASTER gr.JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC D
C/77byI. ADDze ss ,Jei GA-rer1fnAc6
+— r
ri
i y
,1.
}
., ;.
t y
y
cnd r
E -f +-
l
F _. _ _
h �.. ..-. . _. _.. .
i
i (is I
1 •
r, ,f1,:
•
' .gar'_ .� '..•' ,�"}£:L`�_a E". Y,
r` ' a
R
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—,�,7, ij r, C c" 23 PERMIT#
= _f-- i, CITY_ i fi N'► :�; 'l MA DATE •
JOBSITE ADDRESS /_7 htli J Sfr?4-w CC OWNER'S NAME anfli 5 :'4:-6~r F'"4k-
er-
OWNER ADDRESS kh.1.- TEL 5 ' L / ‘3,3() FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL 0 RESIDENTIAL E--7
PRINT � /
CLEARLY NEW: ❑ RENOVATION: 0 REPLACEMENT: (2 PLANS SUBMITTED: YES 0 NO cfrr
FIXTURES 7 FLOOR-I 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/OIUSAND SYSTEM
.
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM .
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN ,
INTERCEPTOR(INTERIOR)
KITCHEN SINK r ,
LAVATORY
ROOF DRAIN 1 , 1 { C.
SHOWER STALL R` --�
SERVICE/MOP SINK
TOILET LSEP 05 3 1
URINAL I ,
WASHING MACHINE CONNECTION
E3viLDiN( DC(,tTM1l:NT
WATER HEATER ALL TYPES
WATER PIPING �-��-
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY I JSURANCE POLICY E3 OTHER TYPE OF INDEMNITY ❑ BOND 0
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 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 P ' ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `O �/,` .,1________
PLUMBER'S NAME J�/��', - I�to� l LICENSE# / ill �' NATURE
MP [' JP ❑ CORPORATION ❑ # PARTNERSHIP 0# LLC ❑#
COMPANY NAME UA1'S l ikr. 4 L I2 ADDRESS a gle.,IigK1 ik
CITY LVII STATE in- ZIP O 7 I _ TEL 77-/ ' i ' t J-f
FAX CELL-1 i`1 43736 ('S21 EMAIL J i 1 (,.,f A_ -z -- Jar &-i i i-i ) i 6a(1
, .
arm. - 4.
......___ _
>MOW 0141141,LI.II 1-Dimr.,---019, :), Avi-.;-,--?zi ,..„. -i•?-•Ji tic.- -_:i. •-4A4-'.":" ' ,
4 1/4/ 0.,-(rs-1-% , *
. • Vrittcla'(' ... . '..:. ' • '•-, -% ,k . ., -P"'- -.Y.,: .........._..._ - ....•- .. . • • ---'71.;.--'-;
r - - , . ,..
Ir.c--•';,..-••••
.•,
,...;',4:''''' -' : ''.•' 'i , VI • •- .;`M.!'1,!""9: ."" .; _ • -..::, r,-•:,. -:'',-2,-20.., ,
, . _.., , ... . , •
_....
. ...... „. _
, c.•,-r. ' ,-, :: .0 1- "P• ,..,.... . (-) , /!-;.- .. , ._,... __,... ,..?,..:::.;:;.,.".!.:`:f• ?::•:_:..141i•,-4 '
....t.:.
•
; '
1.A#Fici -
'.....,
' cj:„.„0:4 0-i" .07:11:151.k.1.-2.1,1kr;- 4..... -1-7-'7.1'• .-_-;`,.'..,.....%$-' ,r-: 124.1....VIC'i!--7 : r . 3-'..,
..... .
: , . :, ,...; ; ,1,, ,. ,..6 i ..- : :-. . • : :... . . _ : • —I::: . -~,sf...,,s••', ‘ i••!,,;,,'1,..0'..'s -
. . ,
'..:-.i-,H.i,•'•.-,
i . ...;-•.,, •,- • : • •.-.1.,t-,..,., .:J.:,:..-1...7. . 1
I- . . ,v .,•j-•'-'?....-:•^i . ...,:,•,:)•,131,46,..Ift .:.`'.-C i
.... , _ .
1
,-; ._;.,. .,:;14.6.,,,it,..f1.?.r;G:i"..::tarii,A1
I
k!....' "l.F.
I , . . . - . 7 "'."' ',' -r,-.•., -f- ct.f:.,,,...,--41,4:-.1j,:r'il
. .
. . ... ,-.4.-i::-.:'.. '-..,'N;'1,64,4:3r,'.',.173i0...,"'If 1.;,.; •
. . ... - •
' ; :. . i I . '...,'"Ir.1,.,,41.!..4..,..7,..- •
:LTT
t
:: • -
( ...
i/f•.`:4.1:4 A.73C•A;Mai
•
i iN?3,,.,-TildEpQ t er-43Frir:1 ,
i ! I
'_41.41Z1,774i0TF• .
`.....1-:.V.,.vi'• : ,
1.4t4.1.7-,--.I--...•:
, •1/4. .-......k ".... ;4.... 4i. 7: 7. J,11..TS..::-.:.:11[1• C' f
' . ... _ -
,'. . ':-_,',.•':',,---1-"-
a f
•.'"; '.).c. 1
6 42111 i a'' —f
. i...l.:,-(.r.i,..'7'.13i-'',1Af-; ''' -.2,:‘.% •
. .
li LP'--:4 ' - - — —7 . ..— -. --"--
tt..
..• '. — • ' ,..a.,
•
"''7 '..A, -.1.1". .•,•!:',4'1.; ;
1 •=7:44i;" ,;::,:.i„....,
,
. , -• — --
)) .,, oir 4,,,..7 i7:4•.., ...:; ,-. r",:;',,..;.„..,4.,.t.),..,-. .qr.„.,11:.,.. .: : .,..,,..t. .;.:-..,1 fj.v.' ,:.....''',' 7: r`... ::"'i.,. 7.. '• - •I .•; - t: •":';', ' ' h. t.,.., •-; ,,,;-.-..r, :
. 14..-.1.....1.'":, ... ''. ...:46s-•••••'-',- •7;•i--::...•','..:•L' ..z•••-• :'.: ',1-.• ,,'":'`, '7:7,1.".re"r?II:,'', --,. ' ::r ..--2!. =4 - .. ..
' .; '' :-.,", -V:i , -, ..::: ,:4 :: • . • ,i ,..'.,:..' T.
.eTif,c 3.f.'r 10:;r4';', ',.....!a...:.r...-.:.-1 •,.ii:•.-1:••:roft ,,!•t .-v,a, _:I-;,i.r,.--rf;.,,i. ,,,-qc: •. '..s,. ,' i.,.. -:. . ," ,. . 7. €0: . .'.'''''..'".p,-,....,-..-., -_.....__ .
'''.'''.--'_:,--'...;q1•••t.i,: ' ..:... ..i.; '•,•'.•:',' : ;. 7±. °"7:i.,...1.,4 if .... .: -..'..:ig 7',.,'.. .-y:.'.!l''.^;`,. ...;, : ...'.,', ,..-•.;') ' ',.;:l.:T.3ii:7:1,-.i
13 ';i3i6tIO 'LAC;:11:.:.;1;`:.•••.... !'' :,-3
... . . . . . _ ___ .. ...... _
....•
•,. 7,H....ivL,.,,,: .':.‘")...:,•:,:,'s 141i:!r,„
,: ,..Aw„rly yv-,,,,,,,,ijaep,..41..„4:,-..-4,--..,!•Fi...1;:-.,,e.4,:::,,;F,i,,:-•f,, ::,,;...„: ,40,1,, •_-*:::,..- ....- • -,--.. ;.:,..,,,;- rf‘oll'- -,''.--. ' , ., ;11.:;,1P..'""t-;.,--- te,t'.. qr.
'' ''-i3OVV::7':... I.1:1*-I•''''! ' %,..%"1,i''..'1'" ' - ' .:-.. . . vC:•"4 ' '! • .7-' • ,:')'.• •'',.:1-!..r"!'•' . .-, 1': •--! ..11i--.7r:j;1;-•",''•.".i':.*P7.•• vf,'.6'riVe_,•:., ":.7 't.Y• :.
•
.f:, •': •••: .-•• ' -.'.''.•••'`. ..•••'''''...• .. ,i` r..,: ,,.:,."-,".i-• ,•,...,
,.. .
'
• - -
',4,,`.','
- •
-. -
i *- 1._
- '
•. .,,, .,. 1 ' ',...
ss -.,. 1 ,.-1'. • rr .' '
....-....... .... ..
s .. . .
$Z . % %,
.
' • -. • •- . ....-. . . ... .. .. . .