HomeMy WebLinkAboutBLDP&G-24-372 ORP: PAgeee :
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY („J (-AO U 1 MA DATE 11-451 PERmrr• BZDA alg 7392—
JOBSrrE ADDRESS /zi) Ace Y"te-/-141ee4ue 1 s muiEfi/ohnrc, Sv,C1
P OWNER ADDRESS I (e Oral 6r4-7/n FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 M10tM. 0 RESJDDITIALfl
PFUNT
CLEARLY NEW 0 RENOVATION0 REPLACEMENT:0 PLANS SUBMiTIED: YES 0 NO03
FIXTURES 1 FLOOR-. mu 1 2 3 4 5 6 7 I 9 10 11 12 13 14
DEDICATED SPECIAL WASTE SYSTEM I I I I 111 II II 11 111 111 II I
DEDICATE)GAS/01USMD SYSTEM
DEDICATED GREASE SYSTEM
II II II
DEDICAT GRAY WATER SYSTEM
II
ED EM II
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRNKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN . .111111111111111
NTERCEPTOR ONTERIOR)
RTC ENK
LAVATORY
ROOF DRAIN
SHOVVER STALL
SERVICE/MOP SINK II III II III 1 II 111 OH NNIIN11111
TOLET
URNAL
• 11111111111
WASHING MACHINE CONNECTION 111 II II 111111
WATER HEATER ALL TYPES
WATER PIPING II
ND OTHER
11111111111111 II
• INSURANCE COVERAGE:
I have a currant filblifty Insurance poky or is substantial equivalent rthich meets the requirements of MGL Ch.142. Mk NO 0..
F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYpi OTHER TYPE OF newer(0 BOND
OWNER'S INSURANCE WANER:I am aware that the Scenes sloes not have the humane coverage required by Chapter 142 of the
Massachusens General Laws,and that my signature on this permit application waives this requirement.
• CHECK ONE ONLY: OWNER CI AGENT
SIGNATURE OF OWNER OR AGENT • •
I hereby cagy that slot the details end infonneSon I have submitted or entered regarding this applicatbn are true end mumte to the bed of my knowtooge
and that al plumbing wort and installatiorai performed under the pent*issued for this application will be in oompbnce with al P provision of Is
Massechusetts Stab PlurnbingiCoa and Chapter 142 ofHO*General Laws.
ra `-
PLUMBER'S NAME I RI Net: 7:R(-ii..ke I UCENSE VV71 ) SIGNATURE •
END J . CORPORATION 00 • IPAFtTNERSHIP1911114 tLLCD#L7PPJ
COMPANY NAME I M P 411— I ADDRESS'Virg/11,4/M A7/1/4ell Li`e
CRY' 4Zti f I STATE FIEL aP / I TELWXYle 7/7,7__ I
FAX II OEU..I . 10.4a rkr0j- el° 3.Ank (
: *.1. 103svikok :emir
AD
_ .. MASSACHUSETTS UNIFORM APPLICATION FOR A PE IT TO PERFORM GAS FITTING WORK
T" CITY IN 41-md li MA DATE PERMIT# ,ZiLDP A y-,3 ,
JOBSITE ADDRESS/ Z.6 i SC 7�e '` 1' —ii tr OWNER'S tLAME, ��r/t-4 0'J1
GOWNER ADDRESS 417 TEt f 7/9? FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL lif
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO I:.
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 _ 12 13 14
BOILER - _
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE J
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN _ _ 1 �I®
POOL HEATER --� ""-
ROOM I SPACE HEATER
ROOF TOP UNIT APit 16 20241 \ 1
TEST ....... __.._ -
UNIT HEATER gu1LDING
LINVENTED ROOM HEATER sy DtaNf2TMCtd+
WATER HEATER
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ti OTHER TYPE 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 ❑
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
.- 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 the ee a al Laws. /767/ \ ^
PLUMBER-GASFITTER NAMEC9r/r§La LICENSE# ` zSIGNATURE
MP 0 MGF 0 JRigt, JGF❑ LPGI 000RPORATION 0# PARTNERSHIP 0# LLC 0#
(�(-1�mi, aez_COMPA MI ,NA ADDRESS 37 7--- ,,,z//4 pitit,a06,,e
CITY 4.n/Its STATE, 4 ZIP e`Z(OD/ TEL ,y! V/D </aZ-
FAX CELL EMAI 11- r/ /
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: $ PERMIT#
PLAN REVIEW NOTES