HomeMy WebLinkAboutBLDP-25-616 c IN-cc I, 3asa
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1'_r CITY yavuno./fl')pd(IL MA DATE (j-/5"- PERMIT#
JOBSITEADDRESS 37 ti/1 Aran d gc1. OWNER'S NAME Mg 81 SJ L if
POWNER ADDRESS SOmt TEL a03'7a7-7Th5FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO n
FIXTURES"1 FLOOR-. 9SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB -
CROSS CONNECTION DEVICE i
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM -
DEDICATED GRAY WATER SYSTEM -,--
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER V
DRINKING FOUNTAIN -
FOOD DISPOSER V -
FLOOR I AREA DRAIN - ---
INTERCEPTOR(INTERIORL V - -
KITCHEN SINK
LAVATORY
ROOF DRAIN "
SHOWER STALL V
SERVICE I MOP SINK
TOILET -
t
URINAL t '
, WASHING MACHINE CONNECTION AUG 1 -
WATER HEATER ALL TYPES
WATER PIPING - _ _ _,
OTHER I r .._
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES gi NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
11 I hereby certify that all of the details and information I have submitted or entered regarding this application are true andppe 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 v/ittb all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER'S NAME LICENSE# a?.7S S' SIGNATURE
MP❑ JP® CORPORATION 0# PARTNERSHIP 0.# LLLC 0# 97 5S-
COMPANY NAME Jack [(a n-c (Ce r rir a(�1^) ADDRESS 3 9 nie K/im°r 124
CITY 5.yG✓✓h• IM° STATE PAO ZIP 0)6 6`/ TEL
FAX CELL Sa Er"Co 85-56S1" EMAIL 7Kanft"I5-Q .joha0 CO Im
• C tUZ cAt'l z$ 30'S a- 5 O—
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
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER it
IOHN KANE `z
19;MMNOMOY RD A.ji.L:YARMOUTH, MA 02664-1984 .
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22755 05101/2026 582386
ENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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