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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY /L Al V II MA DATE f Z45PERMIT# 6Y/)�z5_9OO
JOBSITE ADDRESS O JJ-1,---j2 T 2—"g OWN R'S NAME /7 VA)
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDU IONAL D RESIDENTIAL
PRINT PLANS SUBMITTED:YES 0 NO 0
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 t 6 7 8 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL „0V 2 1
SERVICE/MOP SINK aw
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 Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE VERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1 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 comp nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P
PLUMBER'S NAME LICENSE#/ / SIGNATURE
MP JP (� �gCORPORATTIIIO�Ny❑�# /� PARTNERSHIP
0# JLLC❑Q#
COMPANY N/AAMME/J r, (.�1 J�OVI/l �Oft VI—y'�fBDRESS25-//N27 A I '\t'
CITY \l t t Y W/1 O V i i STATE/ t ZIP 62673 TEL6-0B 3&0 3C
iqS
FAX CELL EMAIL)X44,414 nik 1/1 fCrUd lO
..„ii,;_ :,, .2..,27___ /21 7 z c.:).,,,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT.TO PERFORM GAS FITTING WORK
7 /
t C
s
.,. '. CITY t �M�`�_
MA DATE j f 7� _ PERMIT#
JOBSITE ADDRESS / ( 1 7 ZO OWNER'S NAME jk/11_____ __--5
OWNER ADDRESS 7 Y---- a { TEL TEL
FAY,
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATION RESIDENTIAL ❑
CLEARLY 1 NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS.,SUBMITTED: YES ❑ NO❑
APPLIANCES -1 FLOORS—f 6SIvi 1 ? 3 i 5 6 7 q
BOILER — 9 16 11 t? 1=1_
BOOSTER —
CONVERSION BURNER
COOK STOVE i
DIRECT VENT HEATER
DRYER
FIREPLACE �i
FRYOLATOR
FURNACE
GENERATOR
GRILLE _�
INFRARED HEATER —�
LABORATORY COCKS
MAKEUP AIR UN'T •
OVEN I
POOL HEATER
ROOM/SPACE HEATER ,
ROOF TOP UNIT
TEST —"`
. ... ....... . . ... ....... . . . . . . . .........[INVENTED RO ,
WATER HEATER �_ —�
OTHER
I
Il
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES
q q fVC ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE_BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑' OTHER TYPE INDEMNITY E 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.
SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER El 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.
,.il
PLUMBER-GASFIT"f ER NAME LICENSE#
SIGNATURE
MP p GF B� GF LPGI ❑ CORPORATION❑#t PARTNERSHIP[]# LLC
COMPANY NAME it/64A A / /-1 ADDRESS 27 M%I / 0-6)/1)Y / -
CITY Yn-a---MC/C c-t r STATE t' ig ZIP 0 7-J TEL
FAX CELL () ✓c c (Mg EMAI ' / ( /C a'YI i ov r-j
� G THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
r�ryECTIC►IY NOTES .
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REYLEW NOTES
CERTIFICATE CJIF LIABI...,t.ITY INSURANCE
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