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Home My WebLink AboutBLDP&G-20-005020 ......r. MASSACHUSETTS UNIFORM APPLICATION FOR A ER T TO PERFORM PLUMBING WORK —_ems CITY lip J- G/ r D 1 MA DATE PERMIT# aV JOB SITE ADDRESS p . r 1;, dcf-' V. OWNER'S NAME . r'N)9" /) J PC' ,5 POWNER ADDRESS 7� //)7 TEL 7—/1/. 2 0 2 7 FAX E TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALE 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/01L/SAND SYSTEM I _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN , FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY . ROOF DRAIN i SHOWER STALL SERVICE/MOP SINK TOILET I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I I INSURANCE COVERAGE: IP E V I have a current liability insurance policy or its substantial equivalent which meets the requirements of t'Ch.142:`YES N I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX :ELMW 11202+0 INSURANCEPOLICY FINDEMNITY BOND !;i'" UABIUTY � OTHER TYPEO ❑ . :� �piN�� MENT OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage -: - tlhe Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT l� 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 Code and Chapter 142 of the General Laws. CC�� n Q..PLUMBER'S NAME LICENSE# //( 6 7{ �-�C SIGNATURE MP❑ JP VJ ( (7° In COP�ORATION # PARTNERSHIP❑.# LLC❑# (�� i �� ADDRESS & U y 77 r f t/-tc' i COMPANY NAME V " , J CITY (A- 'Cr `' 41 l' ;/ (k-4 STATE A44 ZIP (0 2Gn 73 TEL 2/� -71/' �l(,) 9/Z'L FAX CELL EMAIL 4'1/\ ...e.,-.,.-LL r t�KJo `,4- r t ' r[ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIC N NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT Ik PLAN REVIEW NOTES 1,-. , .-_, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `= rmrJ, CITY l, f N1 0 3 G--k1 MA DATE 2 69 PERMIT#/W), 6V ll0o 0 JOBSITE ADDRESS 5 P cl r 1/Z t o &'-t° \/ 4-1 1-1-47 OWNERS NAME, 7 Nt47 ,J c__ r //5 GOWNER ADDRESS TELyI - 20 2-7 FAX TYPE OR 1BPE t OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALV CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1- FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 '11 12 •13 14 BOILER 1 BOOSTER I CONVERSION BURNER ■ COOK STOVE i , DIRECT VENT HEATER ______IDRYER, _____1FIREPLACE FRYOLATOR FURNACE II.GENERATOR. GRILLE INFRARED HEATER ❑ ❑ ■ ❑ ■ LABORATORY COCKS MAKEUP AIR UNIT OVE POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER WA OTHER 1 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of[IGLU 1 YS I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX SEL0 ! '� i�AR 11 2020 1 I LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY ❑ L BOND ❑ 02� OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage re iTU dapiii IRS_ ' N Massachusetts General Laws,and that my signature on this permit application waives this requirement. 1 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 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. _ PLUMBER-GASFITTER NAME LICa._. ,...._<-______„ E!' E ` SIGNATURE MP ❑ MGF❑ JP [} JGF❑ LPG' ❑ CORPORATION❑#i P C 0 P PARTNERSHIP❑#1 LLC❑# COMPANY NAME A7C)4 ( r 4)9_42 I'1"C`/ ADDRESS C7 /2 L//`� 7- ))71 v CITY VA., 1 t (_lJ4/( STATE {'WA ZIP (�, 7 7 3 TEL 7 7 KY/ FAX CELL EMAIL) n -Q.i' •A4 f, chi'6 c — nn z 1 i I 1 G.1 0 1 4" 0 Pi . I c) {4 ,...1 I - I I I I wa 4- 1 I o «O W ! E w 0 Z I w = i 1 2 C' C r,- .. .. O > G L COGA G14 G� ‹ �a L..,I r4i ..s CC. CO 61, 119 T lk9 LL 1 r i 0 4 i 0 I () 1 En I - C, C, i i 1