HomeMy WebLinkAboutBLDP-23-11888 V• —,�_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY arIV)OLIR MA DATE ll/?7' 23 PERMIT# LG Z3-fly-W.
JOBSITE ADDRESS I! / 5H-0 R7- GJ/H/- OWNER'S NAME/ .P(c'A
POWNER ADDRESS 64tarfF T Pt EL-7 7755- 7aAX M/2R
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALE
PRINT
CLEARLY NEW:❑ RENOVATION: ] REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 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
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN ECEIVED
INTERCEPTOR(INTERIOR) '4
KITCHEN SINK I fly
LAVATORY ( _ T
ROOF DRAIN Yu Lie v�r
SHOWER STALL 1 -
SERVICE/MOP SINK
TOILET I _ _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES _
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 TYPE 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L t I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a••rate to the est of y knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in co - th al P pro slon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBERS NAME LICENSE#33 3 IGNATURE
MP 0 JP® CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME`t her /rUn�; t ALI-7Y® ADDRESS 3'� N�ni/P�� _en/
iC CITY Or t'S � STATETA /Y)A- ZIP /9-2/7 7 c TEL.63AS 7.2Y(-y7 4-7
FAX CELLAAs-e— EMAIL/4Y/7ta,r1✓Or'S�;�'
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
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DIVISION OF OCCUPATIONAL LICENSURE
j.$4,1,A '-?;ACH14SETBOARD OF / OT TS DRIVOT§
LICEN4t
FOR FEDERAttiD
PLUMBERS.ANIIGASFITTERSI:P'V' • •
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ISSUES THE FOLLOWING LICENSE - 08/18/2021 Or-W:151685
3 DOB
JOURNEYMAN PLUMBER cc
- 07/9712026 07/07/1975
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CLASS
•z 1 1 RENOsINE NONENATHAN J -1,
.f.EN_ADRSKI
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2 NATHAN„I
ROCHESTEW MA
8342 MENDELL RD
4,7 lit);
ROCHESTER,MA 02710-1301 —
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33387 262399 •
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LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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