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Home My WebLink AboutBLDP&G-24-74 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK "_ CITY yar bvtotAk MA DATE I- 1'Zy PERMIT# glIPd y-V /f' JOBSITE ADDRESS I I C/aw(v YATl` OWNER'S NAME C�ottyi zZl POWNER ADDRESS 7 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL-- PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:E/ PLANS SUBMITTED:YES❑ NO❑ FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 _ BATHTUB CROSS CONNECTION DEVICE r--, DEDICATED SPECIAL WASTE SYSTEM -_, DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER • - DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN Y 1 ______ INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY i ROOF DRAIN \ ` 1A� � SHOWER STALL }y !IL c FP1'RTM• SERVICE I MOP SINK \ 0"D"' TOILET A� /� URINAL -1 j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES )E, 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 F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POUCY 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 j Massachusetts General Laws,and that my signature on this permit application waives this requirement. `tr. CHECK ONE ONLY: OWNER 0 AGENT❑ SIGNATURE OF OWNER OR AGENT ZU I hereby certify that all of the details and information I have submitted or entered regarding this applica i n a tru nd accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will a in ance with all Perti ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .3390 PLUMBER'S NAME LICENSE LICENSE# NATURE MP 0 JP Q CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANYL NAME 9(�O��r'e 1 ` RS - P `i ADDRESS J i ^'4— J;sy,k Sr CITY l? '''n S 115- STATE/41 CCt ZIP d42-aO I TEL FAX CELL 1:7 y 836 ‘'( EMAIL 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 • I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY X°rn'LoW MA DATE 1—G202--,27 PERMIT?# 7 JOBSITE ADDRESS I MfrCu.ry OWNER'S NAM OWNER ADDRESS // TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIAL a' CLEA RLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED YES❑ NO APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 5 9 10 11 BOILER 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT'VENT HEATER DRYER L__ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • I MAKEUP AIR UNIT "k_ • OVEN t POOL HEATER • I r '' • r ROOM I SPACE HEATER r ,� '. ROOF TOP UNIT TEST ti iw '� UNIT HEATER UNVENTED ROOM HEATER 'a WATER HEATER // OTHER ♦ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ND❑ 1. I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ v OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General and that m signature nn thio pewretapplication waives this requirement. CHECK ONE ONLY: OWNER 0 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 e and accurat a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m lia wit P inent provision of the O. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lt.) PLUMBER-GASFITTER NAME LICENSE IV_?A SIGNATURE MP 0 MGF❑ JP[fi JGF❑ LPGI 0 CORPORATION❑4 PARTNERSHIP❑Y LLC❑t# COMPANY NAME Par• . `P(4 L. ADDRESS 57 51 CITY \icnn: STATE M c. ZIP JOJ( TEL FAX CELL 77V B 3 ' 6 4(6/ EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: $ PERMIT ft PLAN REVIEW NOTES • • • • • •