HomeMy WebLinkAboutBLDP-25-735 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•==1i-a� CITY �l l �GIQ MOri"I �1 MA DATE ? 3 0 ?-5 PERMIT# LOP---2J`7:1)
JOBSITE ADDRESS ? h Ye0 in all Cl r,-e OWNER'S NAME
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAI.
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO/::1
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM --1
DEDICATED GRAY WATER SYSTEM 1
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _ _
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL t qpq
WASHING MACHINE CONNECTION �3 Q�LL5 ;
WATER HEATER ALL TYPES
WATER PIPING ----
OTHER 11____. ' rr.:'-fcr
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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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
LUI 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 corn • nce wi II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter/142 of the General Laws.
PLUMBER'S NAME Jv5e �CQS-11 A O LICENSE#,3Cib3 •J2 SIGNATU E
MP❑ JPPJ ( (ITC--7s CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME /4 "'p ir/A/J//7 ADDRESS I' /6 td C 3'4- m ci i r S T
CITY IV CYAA I..5-' STATE/ ' r r ZIP 0 D-G 0/ TEL 5 G/Jr�3 75 3C7
FAX CELL EMAIL A t.✓r ie scp Cf CJ y� ,y/01A %n 7
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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
•
4iDIV" IN OF OCCUPATIONAL LICENSURE
BOARD OF
1PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER !�
JOSHUA A CARLINOv
PO BOX 149 .
CENTERVILLE,MA 02632-0149 W
30034 05/01/2026 614136
ICENSE NUMBER EXPIRATION DATE SERIAL NUMBER