HomeMy WebLinkAboutBLDP-24-51 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-e-@ CITY i.-r�,� kL p ra" I, LOB'21 5(
-L a / . MA DATE I- rd_ L"I PERMIT*h
JOBSITE ADDRESS I Li K L OWNER'S NAME RAI c{a.vt S
POWNER ADDRESS TEL FAX____________
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[g/ PLANS SUBMITTED:YES 0 NO 0
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 5 7 B 9 10 11 12 13 14-
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _--.1
DEDICATED GAS/OIUSAND SYSTEM ____.
DEDICATED GREASE SYSTEM -
DEDICATED GRAY WATER SYSTEM -
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER i • -
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK f
•
LAVATORY
ROOF DRAIN
SHOWER STALL r C ' "
SERVICE/MOP SINK ____ h
TOILET 'A�I -7p��
URINAL _ JAL] 1 z 2O24 "
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES - SU,LDINC UEr',RIME NT
WATER PIPING By —
OTHER
Tc._ k,yJ`-✓ f _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY C21 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
LJ 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l� --------_.
PLUMBER'S NAME
LICENSE#�6. 1)._ SIGNATURE
MP❑ JP El CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME C-I,t- Liy-e. P-J-14
nn ADDRESS -)---ifr7G.fiLa S'gs rIFS
CITY iycck4 4,,. STATE 17 ZIP U 9-//..�O 4- TEL 3. 3/`y�L(�`�
FAX CELL EMAIL r;.•L Q r-e_ 3..._yol--+ 0,
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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
COMMONWEALTH OF
DIVISION OF OCCUPATIONAL LICENSURE
BOARD 0
PLUMBERS AND'GASFITTERS
ISSUES THE FOLLOWING LICE103E
JOURNEYMAN PLUMBER (�
CHRIS LAQUE Z
24 IWADRID SQ
APT 5
BROCKTON,MA 02301-1252
26692 05/01/2024 248578
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER