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�� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_:a_ CITY 0./‘1 - l (/
`==1_f=a MA DATE �/��q PERMIT
JOBSITE ADDRESS.�S/ /17e. OWNERS NAME JOhn LAJ47 ,,,j
P OWNER ADDRESS .CS//,V to AI4G TEL7A-ST/-/3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:V REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM --
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM -
DEDICATED GRAY WAITER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER /
DRINKING FOUNTAIN
FOOD DISPOSER / _
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
LAVATORY 3 3 _ _
ROOF DRAIN
SHOWER STALL / _3
SERVICE I MOP SINK
TOILET d2 -3
URINAL T — -
WASHING MACHINE CONNECTION / -R E C 0 V F
WATER HEATER ALL TYPES
WATER PIPING / T
OTHER = IAN _9 2[24
O/fTQ)f 64,w)C+" -2
.5/LLlGY'/l,S o7 RIJILJING IEPAF.TMENT
BY <_— _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O NO Er-
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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
j Mass setts General Laws,and that my signature on this permit application waives this requirement
,4\\l,',,______---- CHECK ONE ONLY: OWNER Er AGENT 0
SIGNATURE OF OWNER OR AGENT
-..1 I hereby certify that all of the details and information I have submitted or entered regarding this application a e and accuraTe'10 the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in mplian wi I Pertiflent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBE 'S NAME / LICENSE#// �de,,p ij p SIGNATURE
MP[C" JP❑5 4fivr CORPORATION❑# PARTNERSHIP Q#7vn/J_�f�,� LLC❑#
COMPANY NAME 2 ) �Lt/4/A4'itk i/ i ADDRESS ax-r9 .4or'H&/r/i' L!/L)
CITY 'UY/'e STATE/09 ZIP Doi SSf3 TEL 771-S7/`/3/C>
FAX CELL --Corn EMAIL '/ YYd)/'1 &y4/ !.49/77
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
r
III 016i me IA :.
■ U
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
MASTER PLUMBER CC
KEVIN M DOW
120 COTTAGE ST N
FRANKUN,MA 02038-2209 ''
11600 05/0112024 234476
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER•
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.�"" "'� — LICEN � �,I
RVISIO jC\►A OCCUPATIONAL DIVISION OF BOARD OF
PLUMBERS AND GASFITTERS
FOLLO�NG LICENSE
Jt4rRN
ISSW S Rt1E PLUMBER
16
,
KEVW M DOW «`
120 COTp►
FRANKI INI MA 02038 22
2�90 , v',.Y w
SERIAL NUMBER
EXPIRATION DATE
�' . LICENSE NUMBER