10 12 GENEVA _PLUMBING & GAS 11.22.16 ./ j - 9 CA- �7-30
A. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING'WORK
3 CITY _ �/1 MA DATE' 1\-a l(� ,PERMIT#
NMI, _
JOBSITE ADDRESS � Z Cp r� -�/�� OWNER'S NAME C �
P OWNER ADDRESS C TEL, ;FAX
- -- ---
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO,
FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 8A maim 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE -
DEDICATEDSPECIALWASTESYSTEM
DEDICATED GAS/OIL/SAND SYSTEM A
I f
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN '.
FOOD DISPOSER
FLOOR/AREADRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK 1
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET V
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES _ _
WATER PIPING
OTHER
i
INSURANCE CO
I have a current liabilityinsurance policy or its substantial equivalent which meets
meets the requirements of MGL Ch.142, ve5 No
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOWl`-
LIABILITY 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 AGENT hGt
SIGNATURE OF OWNER OR AGENT L—
I hereby certify that all of the details and information I have submitted or entered regarding this application are t .aqd accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i mplianc with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME' : LICENSE If SIGNATURE
MP JPE CORPORATIONA# PARTNERSHIPEI#FLLC #j
COMPANY NAME J?(UJo ADDRESS
CITY!_ �� :� —STATE �Y7K1 ZIP I Q U TEL
FAX L______.._ . CELL EMAIL g �10
C'r qla17W
'C\- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 2LVb'� MA DATE �\ ka-�. .. PERMIT# y�/C1
JOBSITEADDRESSIA/2_ OWNER'SNAME
GOWNER ADDRESS TEL FAX ,J
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:), LAN ED: YES NO
4 fit
U
VFLOORS—; BSM 1 2 3 4 5 6 7 12 13
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER IE I I
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES 0
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW l'
LIABILITY INSURANCE POLICY\ OTHER TYPE INDEMNITY BOND I
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
I hereby certify that all of the details and information I have submitted or entered regarding this application are tr�a curate to the best of my knowledg
and that all plumbing work and installations performed under the permit issued for this application will be i npliance th all to provision of the
Massachusetts State Plumbing Code and Chapter 1.422 of the General Laws.
PLUMBER-GASFITTER NAME LICEN SIGNATURE
MP MGF[,,,,i JP JGF LPGI CORPORATION�C# PARTNERSHIP # LLC #
CO ANY NAME-
CITY S tJ �S STATE " ZIP Q TEL
FAX CELL CIS%()q7j EMAIL
CITY OF SALEM
PLUMBING AND GAS INSPECTOR
ADDRESS i
LICENSEE'S NAME/COMP NAME
LICENSEE'S CONTACT NUMBER
PERMIT #
TYPE OF INSPECTION 13 PLUMBING ❑ GAS
INSPECTION TIME -
❑ ROUGH ® FINAL ❑ SAS TEST ❑ OTHER
• ' _ 3 CJiV1ME'-
. sT'
r
TS
La
✓e17
4AA'�Ea,�d se
PERMI OSED ❑
MICH J GUIDA SR
PLUMBING & GAS INSPECTOR