HomeMy WebLinkAboutBLDP-25-755 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_LI=s CITY 1 girt D L-441 p 6(+l MA DATE illf 6/a 5-- PERMIT#& P-Z.S-7Cc
JOBSITE ADDRESS Z C row'(u C)l D r- OWNERS NAME Li E
P OWNER ADDRESS 5 4,--c. TEL f,6 E Z 7 9 O yZ AX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL O-----
PRINT
CLEARLY NEW:Er RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑
FIXTURES? 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER ' —
FLOOR/AREA DRAIN g F . j I `.: �„�
INTERCEPTOR(INTERIOR) — --- - """
o_G
KITCHEN SINK r----
-
LAVATORY ,� I' ..5_
ROOF DRAIN
SHOWER STALL
grill ING C�EPARTMEN
SERVICE/MOP SINK BY _
-_TOILET
URINAL 7 - -
. j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER [:.(,(C.k'("I le/
19 re{y toy-a,r I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E:(NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY❑ BOND 0
' OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
LLl 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. cf 2 �(/L, ��
PLUMBER'S NAME LICENSE# 1 7-`I Z.S.o SIGNATURE
MP El JP 0 • CORPORATION❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAME_Dem IMrj14h46. Id-f+/ �A ADDRESS yf 1t(Gt et/LI4vy ei5 5(✓J)
CITY 4-4 r ?Ct/V0 14-‹,. (e STATE/4'./ ZIP D l 1 TEL .5—Of 22/-/S'c
FAX CELL EMAIL b i 4/-(17 /1 I YG4 CO. C'0.^-r
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT it
PLAN REVIEW NOTES
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* •MM•NWEA TH •F 4 ACHUSETT
• DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GAOFITTERS
ISSUES THE FOLLOWING LICENSELLI
MASTER PLUMBER
DANIEL E MELANSON
41 TWICKENHAM XING �w
W BARNSTABLE,MA 02668-1153
12926 05/01/2026 571865
SERIAL NUMBER
LICENSE NUMBER EXPIRATION DATE