HomeMy WebLinkAboutBLDP-24-752 - . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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E CITY /ak c Witt' MA DATE PERMIT# 1L '1 -.2V" 7S�
JOBSITE A DRESS OWNER'S NAMES 7h4P 13 O4 f
POWNER ADDRESS 03 •Ld( 4,1o) N L a/2n QtJ - TEL,2 •�Y�9G:3 4 S: FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:2 RENOVATION: E REPLACEMENT:❑ PLANS SUBMITTED: YES E NO❑
FIXTURES 7. 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/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
I LAVATORY _
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
, TOILET
URINAL R tC EIVEJ -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES AUG 2 1�
WATER PIPING
OTHER _.
BUILDIN(-1L1Fn TroFA4- r
1 — —
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Vij NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYM 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER Ex - AGENT E
SIGNATURE OF OWNER OR AGENT
.' 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 c Fiance v t II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / q 'J( J.
PLUMBER'S NAME LICENSE# 11 2 b /. SIGNADRE
MP K JP❑ CORPORATION®#,5'o C PARTNERSHIP❑.# LLC❑#
COMPANY NAMEJo,%, Pt h40 P' tt ADDRESS N, ? ✓v hey- Si
CITY �c� e STATE .�4 ZIP 0 l S�i� TEL
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FAX CELLS -'t q l 3-22 L EMAIL/�4'ti • P[i i CDcMei bit)
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SE12=1WES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAR.REVIEW NOTES
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Fold,Then Detach Along All Perforations
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DIVISION OF OCCUPATIONAL LICENSURE
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PLUMBERS AND GASFETTERS } •
• ISSUES THE FOLLOWING LICENSE
MASTER PLUMBER
JONATHAN S FLANSBURG cg •
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291MONROE,ST
DOUtr` 1S,.M 1 01516-2305'
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11969 0510112.02E 576283
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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