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Home My WebLink AboutBLDP&G-25-345 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Tg- se CITY VU r YYY O trI YK MA DATE ' —/0 T Z J PERMIT#BL 0 f-2 S - 3`1 S JOBSITE ADDRESS /2/ cos h'f Sf P' 59 OWNER'S NAMET ray/ I cku rice_ POWNER ADDRESS TEL FAX________ TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL® - PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: — PLANS SUBMITTED: YES 0 NO❑ FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 a 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 —1 DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN r -1 INTERCEPTOR(INTERIOR) p E C. L KITCHEN SINK r� LAVATORY ROOF DRAIN APR 16 2R25 SHOWER STALL _, SERVICE/MOP SINK _ allll DING )E A TrvEN4 TOILET or --- URINAL _s WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I _ 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 OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY 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 i Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER❑ AGENT 0 Z. SIGNATURE OF OWNER OR AGENT L: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 knnwledg and that all plumbing work and installations performed under the permit issued for this application will be in co (lance with all Pertinent rovision f the Massachusetts State Plumbing Code and Chapter 1 2 of the General Laws. CIS '� PLUMBER'S NAME LICENSE# �3/�6 V. SIGNATURE MP JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC❑# COMPANY NAME C.'B 11.llh ``)1vl1, }-{1QC&4I 1 q ADDRESS 7® & 2'2'? ' CIT Y 6 do.6-1/1 I STATE ZIP TEL 6 1-'3 TEL FAX CELL'— O/--7976 EMAIL Gp U Mb1YtU 1 3 /< 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 SZ2i, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ==yytl=:" CITY: Yu' rmTiu4\ MA. DATE Li 1 d'"Z 7 PERMR#QLOC-v-r JOBSITE ADDRESS: / J C W1(� r "!/OWNER'S NAME: t� Mau.el CC.G OWNER ADDRESS: 1 TEL: FAX: TYPE TOR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NO❑ APPLIANCES? FLOOR—. Bowl 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 In INFRARED HEATER RE C E 1 V E D tU LABORATORY COCK k MAKEUP AIR UNIT � POOL HEATER APR 1 6 2025 ROOM I SPACE HEATER J ROOF TOP UNIT BUI_DI Ne.DEPART/11ENT TEST Z UNIT HEATER 11 UNVENTED ROOM HEATER WATER HEATER / 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 have checked=please Indicate the type of coverage checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY❑ 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❑ AGENT❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this epptcatlon are hue and accurate to the best of my Knae.iedge and that all plumbing work and installations performed under the permit issued for lids application wit In compliance with at Pertinent provision of the Massachusetts State Plumbing Code and Ch pter 142 of the General Laws. ��Gy PLUMBERJGASFITTERNAME' 10.Y\ '—'. Q / LICENSE#/3/C`f SIGNATURE COMPANY NAME: ale:. / b�V ' vYv� Ny 7447 ADDRESS:T6 �i vo Z 2'Z2 CITY:C�Q'1 0 u�,v,5 1 1STATE: k-- ZIP: C'Z6', FAX: TEL: CELL S' ?6/-?1i MAIL: c--N 11 L mP eYL t 3 C /(/yi ail,ca f'1 MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# c h79it, ADDze•SS: ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMITS PLAN REVIEW NOTES 1