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Home My WebLink AboutBLDP&G-23-11376 gG.O ) MAS CHUSETTS UNIFORM APPLICATION FOR PE IT TO PERFORM PLUMBING WORK =r, CITY i MA DATE 3 P_ ?�//37,6 _e�_s PERM JOBSITE ADDRESS E � 1.4.11i ''d/�d/Vk r�At e OWNER'SNAMEa:9 1464", V/0j/4,7 POWNER ADDRESS If tali f L %IOZ I/v� Tat rM.Of/r `t TEL 7 7 Y ii77,7-nzFAx TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[E PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:04. PLANS SUBMITTED:YES 0 NO E' FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 6 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 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET `. EIdF 1 URINAL _ WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES I .UN `k.(1 2023 [ WATER PIPING OTHER _ F11111 nINC.r1FGn 4--AA[ Y. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a.NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY®., OTHER TYPE OF INDEMNITY 0 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 Z SIGNATURE OF OWNER OR AGENT 14.1 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 umbing Code and Chapter 142 of the General Laws. �j n y� PLUMBERS NAME'I Chat A.C) rtdPz LICENSE#I!W `SIGNATURE MP❑ JP L (�� II�� CORPORATION❑# PARTNERSHIP❑# LLC❑# Prof' COMPANY AME U"l C/J r ldp Py—t4 /� ADDRESS 37 �-(rnLLi . r4 CITY *4 i AU 5 STATE flA4 q �ZIP 0 z (pO / TEL 777 7�4 /�G .. FAX CELL EMAIL A0 er •NLrLaLIdlo (Y,/n.. 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 _ f� . , MASSACHUSETTS UNIFORM APPLICATION FOR A PER IT TO PERFORM GAS FITTING WORK CITY 'jtf l�T`�6/ MAGATE PERMIT# -23-// JOBSITE ADDRESS 76.4 1 A_J/r_14 62iCiel OWNER'S NAM I/9-1 GOWNER ADDRESS 11balIR0(pT Lk/14rM- TEL 77/q77-g17zFAx________________ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL tsf CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:gl PLANS SUBMITTED:YES 0 NO[a 1 APPLIANCES 7 FLOORS 58M 1 2 3 4 5 6 7 8 9 10 11 12 13 1_ BOILER - I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYDLATOR FURNACE GENERATOR I GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST • UNIT HEATER , 13 F C E V 1■ UNVENTED ROOM HEATER r I - WATER HEATERJUN I JUN 20 2023 I 1.1 BL,ILDINH DEf•ART\1=NT INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES in NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE 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 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 `I- 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. jG/�/ \ �� PLUMBER-GASFITTER NAME VI aeL 4 cArt t LICENSE# SIGNATURES tc) MP❑ MGF 0 JP Eg JGF 0 1�LP�"GI❑�J ,CORPORATION❑4 /r. PARTNERSHIP❑# LLC❑# COMPANY'lAME 0I Cf. C/�X l[ /" 7-tv ADDRESS 7J1 ��`znLt.l n /1/44P • CITY 1 GL��t S STATER' ZIP U ZG 6/ TEL 7// O�O �//7i� FAX 6666 CELL EMAIL � pr n . - e" • I 1 G"1 G 4 p 4p� . b' at co wN I 4 I 1 I 4 4 i G '^ w w >- 1CO v.a t c G a 4 c.A x F- cr2 of-a, �. ! a > . w UI r4 co 4 0 a, D., < . ri 111 lU 1 E lt! r U. un I c G I I I. up . 1 - 0 0 a4 1