HomeMy WebLinkAboutBLDP-24-281 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
WORK
CITY ` AAMOITJ71 MA DATE 3 - aI-a4- PERMIT# &LtP40y'_Qv
JOBSITE ADDRESS .3(p C gA tR ST OWNER'S NAME j A/1 6g2l/4 6
OWNER ADDRESS 3/0 ( /r7IR 5 TEL-508.NJ-dSD/FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 j 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK r '
LAVATORY
ROOF DRAIN S/
SHOWER STALL I VM R`2, Z"
SERVICE/MOP SINK
TOILET t MINT
yAk
URINAL a 1lLv
WASHING MACHINE CONNECTION ur
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 Of
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY ❑ 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
Massachu s General Lan and that my ig�e on this permit application waives this requirement.
X JAI. l//� Ct CHECK ONE ONLY: OWNER g AGENT 0
SIGNATURE F OWNER R AGENT
I hereby ce that all of the details and infollllll{{{{{{nnnnnnatlon 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 Pert nen provision of the
Massachusetts State PlumbingT� Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I f40I'm S T 1-101-P1 c 5 LICENSE# I a,$3"). IGNATURE
MP 0 JP 0 CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME—{140(1r , 5 YIDLIVl*1) ^A ADDRESS a'% MPrD)60h)r751-
CITY 1 A V N� �V pp STATE I''h"55 ZIP 0�� U TEL I 1��calk ar,4'7
FAX CELL? ?4 210-04'l EMAILTdmhbLMC55@.1'C)DUO. (6t"1
DIVISION OF OCCUPATIONAL LICENSURE
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PLUMBERS::AND GASFI ;::'
ISSUES THE FOLLOWING LICENSE
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MASTER PLUMBER s
T.HQMAS J HOLMES::::::::< ....
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MADISON::.ST# E: T <::
TAUNTO , A �2780-'1 35. W
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12832 05f0112024 293720
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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