HomeMy WebLinkAboutP-14-407 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I
r2}
r I n e CrIY UAt YG t 0100Th MA DATE / a'/t -/ '3 PERMIT# /"// YO7
JOBSITEADDRESS 3/ 5/p//'4 t•vS y OWNERSNAIdE Pc/y /e3j r4 f.>Ty
POWNER ADDRESS 5/ 5"r/teci t2 c, y Tia//`>ce 3?9 -397
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDSMAL 521.
C PRINT
NEW:0 RENOVATION:0 REPLACEMENT:0, PLANS SUBMI I i ED: YES 0 NO Zi
FIXTURES 1 FLOOR-+ I BSMT 11 12 13 4 I 5 B I 7 I B 9 110 11 12 .I 13 14
BATHTUB I
CROSS CONNECTION DEVICE -
DEDICATED SPECIAL WASTE SYS I
DEDICATED GAS/OIL/SAND SYS I
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS I _I I
DRINKING FOUNTAIN 1
DISHWASHER I I
FOOD DISPOSER
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR) 1 I
KITCHEN SINK I I I
LAVATORY.: - I I
ROOF DRAIN" I
SHOWER STALL 1 I{
SERVICE/MOP SINK • I I I
TOILET
URINAL I I I
WASHING MACHINE CONNECTION I I I I I I
WATER.HEATER ALL TYPES I I I I I I I
WATER PIPING f I I I I I
OTHER Sfr icr /I4/v-e I / 1 I
I I I f
C
II
• • INSURANCECOVERAGE
I have a currant liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes p No❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EA OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAVER 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 BOX ONLY: OWNER 0 AGENT 0 •
Signature of Owner or Owner's 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 PertinentP rovision of thq Massachusetts State Plumbing Code and C r 142 of the Ge La .
PLUMBER NAME '3f)hri ()6-rfn04, SIGNATURE h fi t/ 1_
UC# 3dY' 9 MP❑ JP al CORPORATION ❑# P ERSHIP ❑# LLC ❑tt
COMPANY NAME C r/9, yr y/A ADDRESS: a/ 5-1
rte75 Dr
CITYl4'r / /p/C it , STATE /-1 i9 ZIP dJS7EMv+IL
TEL -71g -d 5 /yam caL "77y dC 3 -iv. REctt
1
BEC li 2013 /` \,I
i EPAR tS \ G/, //-
ov __----
FINr rivcrr(`TIONNOT"
ROUGH PLUMBING INSPECTION NOTES TIRS PAGE FOR INSPECTOR USE ONLY
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMITII_
PI AN REVIEW NOTES
•
I
•
.. COMMONWEALTH OF MASSACHUS,RTTS
. DIVISION OF PROFESSIONAL LICENSURE:BOARD OF
-PL MBERS AND GASFITTERS
LICENSED AS A JOURNEYMAN PLUMI}EBJ
ISSUES THE ABOVE LICENSE TO. ..
Ifff JOHM_A GRENDA
21 ' SIESTA DR t
P",WAREHAM MA* 02576-111 I
30788 . 05/01/14 151609
;
LICENSE EXPIRATION DATE : �SERIAL ..::
I
NO." .'• `s�