HomeMy WebLinkAboutBLDP-24-379 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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•—mac '1d�`2 PERMIT#B P cQV 3--� a CITY SO 7 A r.r. 7 irl MA DATE L(
JOBSITE ADDRESS L A Z-a(e-o- La.t e_ OWNERS NAME I -"1 Sp to z
P OWNER ADDRESS t 4-in s .14- TEL 612—Yi3—S%Pk
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIALeff
PRINT
CLEARLY NEW:❑ RENOVATION:rgil REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO gt
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 GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIORL
KITCHEN SINK R S; G 0
LAVATORY I • _ �J
ROOF DRAIN
SHOWER STALL tS 2021
TO MOP SINK I ' E UILUIVU'EPARTNENT
TOILETILET
URINAL - L
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESY2 NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY f' 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
LI I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 pliance with Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �-
PLUMBER'S NAME 40-r r 1 Q C� v e- LICENSE# 19 42-. SIGNATURE
MP IN JP❑ CORPORATION 0# PARTNERSHIP[ # LLC❑#
Y COMPAN11 __NAMEI r�7 �-�� Plug l� f I ADDRESS 4 c. -rO` phi✓c5
CITY 1 1 OV ter- STATE MQ ZIP 0.2 L,339 TEL 40 f? yr ')77?
FAX CELL SA.^t< EMAIL hQ s r Laq U e /a-0.9 ►r. Lo M
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
v COMMONWEALTH OF A AtHU �.. i
DIVISION OF OCCUPATIONAL LICENSURE
BQARt Of
PLUMBERS AND CASFITTERS
ISSUES THE FOLLOWING LICENSE
MASTER PLUMBER - .
CS
HAROLD A LAQUE JR • -
95 PONDEROSA DR' •
HANOVER,MA 02339-1.170
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9982 05/01/2024 256908
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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