HomeMy WebLinkAboutBLDP-17-004042 &. mow !
I � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ^O MA DATE PERMIT#AP /7 cv g0yew.
JOBSITE ADDRE OWNERS NAME/3i0//
OWNER ADDRESS/6; x7"4 8.02JA0i2n TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL P
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO e
FIXTURES T 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
F---E C, E
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DEDICATED GRAY WATER SYSTEM ,,, i,.:
DEDICATED WATER RECYCLE SYSTEM
m_.'ry
DISHWASHER
DRINKING FOUNTAIN FEB- �u i
FOOD AREA 1 f �i (/
FLOOR/AREA DRAIN `T
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY ^� • _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
j WATER HEATER ALL TYPES
WATER PIPING
1 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. YES 1,240 ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ 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.
CHEC 'NE ONLY: OWNER ❑ e NT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application . e tr e and accurate t. e be•. of y k o edge
and that all plumbing work and installations performed under the permit issued for this application will be in co plian e with all P: e or, ision the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .,
PLUMBER'S NAME LICENSE#7�1�71 SIG ATU
MP RV. JP ❑ CORPO TION ❑# PARTNERSHIP❑.# LLC
COMPANY NAME Old P449 /p ADDRESS /cl� 40 �12,5 /PC1/
CITY ( .O6/ / /7.1)/ ATE, ZIP Oath V•_.5". TEL a(: 7/ 7
FAX5O7 0,VZ5 CELIt)L7/75 EMAIL J ?06 Cd/Ol( c 7 i ,eL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
p6,
FEE: $ PERMIT It
cyc6 PLAN REVIEW NOTES
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COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF � ;;:.
PLUMBERS AND GASFITTERS
LICENSE •
ISSUES THE FOLLOWING •
LICENSED AS A MASTER PLUMBER
JOHN B GOUGH JR z
1F46 ORLEANS RD
EP. T HARWICH, MA 02645-2146 `\
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10088 05/01/2018 40694 ' `'
LICENSE NUMBER EXPIRATION DATE SERIAL NUMB
3i
v. COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS z
ISSUES THE FOLLOWING LICENSE
'LICENSED AS A JOURNEYMEN PLUMBER
JOHN B GOUGH JR
1646 ORLEANS RD -.
EAST HARWICH,MA 02645-2146
W
\iJ
19228 05/01,2018
• *, DATE SERIAL NUMBER