HomeMy WebLinkAboutBLDP-24-516 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
51-' / r/3ol aY PERMIT# ,BLDP-°y'5I
.<_I CITY 'f4 R rnua7 MA DATE _ /g
- I JOBSITEADDRESS s�S7 S fA (!u" 4v -- OWNERS NAME / rye, ZGG �Q�f
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0/- ED ATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES 0 NO 0
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 _ _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN -
SHOWER STALL • C- I VE-1
SERVICE/MOP SINK r- -.
TOILET �y
• j URINAL , Vi' a Q OPA�.r(�7 -
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES BUILPINGP-J T
WATER PIPING ar_ , _
Otv•-e �t on self 1
Rt, .�. PVC,
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
LU 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 compile with all Pent provision of the
Massachusetts State Plumbing Code afrd Chapter 142 of the General Laws. A4/1
PLUMBS 'SNAME I Wr s, LICENSE# SIGNATURE
MP( JP❑ R ell rC�OgRPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME r-o S r`""`'Ai - k�7, ADDRESS S 1.3' at. (ass R.ti' R�
CITY PA 0 STATE jtt ZIP C4`sr // TEL
FAX CELL71/ 3f3 &Y7/ EMAIL /Anil:fszlq l C4-1C..1^
afi///d0.9S6 (0 /c 2e/_(,0\
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
7. ,;iCOMMONWEALTH OF MASSACHUSETTS ..
' DIVISION OFOCCUPATIONAL LICENSURE
BOARD OF
PLUMS:RS AND.GASFITTFRS
ISSUES ThE FOLLOWING LICENSE
MASTER PLUMBE
ROBERT R WII 3ON
592 OLD BASS RWER RD
DENNIS NEA 02639-2530 LL
S 5509 W201/2024 269252
ESE NUMBER EXPIRATION DATE SERIAL NUMBER•
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