HomeMy WebLinkAboutBLDP-23-10698 (2) MASSACHUSETTS UNIFORM APPLICATION FOR
IA PERMIT TOPERFORM PLUMBINGWORK•
• CICIAO C`WtO ul Y'1/\ MA DATE 3 Z PERMif#-(-IMP`
JOBSITE ADDRESS 7-' G 1O J S I OWNER'S NAME Lic)t 1)0
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OWNER ADDRESS TEL{ u-64/2 lFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL
PRINT /
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:I/�' PLANS SUBMITTED:YES❑ NO 0
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/OIUSAND 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
LAVATORY _
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK -
TOILET
URINAL
, WASHING MACHINE CONNECTION
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 Cip 14. B
IF YOU CHECKED YES,PLEASE INDICATE THE7PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITYINSURANCEPOUCY V OTHER TYPE OF INDEMNITY❑ BOND❑ : JUN 08 2023
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required ter 142 of the(� �yCl?�R
Massachusetts General Laws,and that my signature on this permit application waives this requirement. I -t MENT
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
L1.I I hereby certify that all of the details and information I have submitted or entered regarding this application are tru and accurate to est of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in co lance wlthial ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME tikAgM'I 14 JsVIriCt6Z I LICENSE#15zr6. SIGNATURE
MP JP 0 f /n CQRPORATIO/N❑# t PARTNERSHIP❑.# LLC 3
COMPANY NAME Y�d41"p1 iiQ-AgeI 9-Pi"ADDRESSS It'J (�1r(14�Je-- L"✓1 �q
CITY (�,�C�s} b(-P STATE M�l ZIP (22(,23/�C� TEL 5� 3(� 7Y"t
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` I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO�7) PERFORM GAS FITTING
:..• _ WORK
4; CITI/ a�� OV� I� // Z
;�. — h , DATE b
1 PERMIT
JOBSITE ADDRESS 2 C ( cQ J . ,5t OWNER'S NAME wire(( U
GOWNER ADDRESS TEL !' 6 if 2 'O 7/
TYPE OR FAy
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E'
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:
PLANS SUBMITTED: YES 0 N0❑
APPLIANCES 1 FLOORS--+ BSM 1 2 3 4 5 6
BOILER 7 8 9 10 11 12 13
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER F Y
DRYER
FIREPLACE
FP.YOLATOR I
-
FURNACE -
GENERATOR ----
GRILLE �_J
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM f SPACE HEATER
ROOF TOP UNIT
TEST -..
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
OTHER
I
- {
INS
I have a current liability insurance policy or its substantial equivalent ntwhich meets the requirements of MGLI CR1p P,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA .BY CHECKING THE APPROPRIATE BOX BELOIi' - C D
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITYt �
El /BodtJPJJ(3 2023
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requi eC�ia ter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement. � 'Np� U �ARTM
. FNT
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd accurate to the est of my knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in CM ' with all P nt pro ' n of the
1.11
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME fldcol )-1-urryC�C. ( t LICENSE#iS-iA, SIGNATURE
MP lldMGF❑ JP ❑ JGF❑ LPGI ❑ CORPORAT El# PARTNERSHIP # LLC 7#, 2
COMPANY NAME Ma \ H.k/�A(� t?A PI ) lb7
� El
l � _ ADDRESS � �r�` Q � � L ►�
CITY S -6 )--e__ STATE 141 q ZIP 07 L"3 0
�7 q 1 � TEL r�
FAX CELL -3(7 -7 Y°1 EMAIL ( r� I 1 i- 4 Q-0.._sAinco5 ✓� 1
OUGH GAS I SPECTIGI�( ° ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: $ PERMIT#
PLAN REVIEW NOTES