HomeMy WebLinkAboutBLDP-23-11821 c(c1i 3d1q
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY S/ a(r^ MA DATE ICI31113 PERMIT#AL,OP'23//1.2/
JOBSITE ADDRESS 3 9 m O ri a to dr/ d OWNER'S NAME Ju c Ic Karl c
OWNER ADDRESS Su t'Y1 c TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 4
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:121 PLANS SUBMITTED:YES❑ NO[d
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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIORL
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL j RE CE ry —
WASHING MACHINE CONNECTION j
WATER HEATER ALL TYPES fn1 fr+T nn� '
WATER PIPING '�L r 3 1-cuLJ
OTHER L
BUI_DINE,DEPA ZTME JT
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES$I NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
4.1 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 compliance th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
/(4•`
PLUMBER'S NAME LICENSE# a-a7SS SIGNATURE
MP❑ JP CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME Jo(lc Kane KOY ?F cc{rmy ADDRESS 3 6t Moo,mOV?cc
CITY S.'/G "I STATE mcl ZIP 0 34 6 H TEL S-O tc E 8"5 -56 SZ
FAX CELL EMAIL jkavr1_eLI3 oLyabco cd-1
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
0 COMMONWEALTH OF MASSACHU ETTS
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER
a
•I+71-IN KANE �1}
Z9 MONOMOY RD \\.) �
S YARMOUTH, MA 02664-1984
4j1
•
22755 05/01/2024 217787
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER