HomeMy WebLinkAboutBLDP-26-125 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
qn (�Z , P Z6—/2�-_){_ CITY V� MA DATE 7 � � PERMIT# �7
• JOBSITE ADDRESS 6f' pC g i OWNERS NAME Ili (o-yl C5->-rdo
POWNER ADDRESS 965 R-1— TEL 5' f1 5 l(z- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:,] REPLACEMENT:4 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL •
SERVICE/MOP SINK Y s
TOILET E m
URINAL
j WASHING MACHINE CONNECTION FEB, ! : 1 2 202b _
WATER HEATER ALL TYPES 3 ,
WATER PIPING
OTHER 1
INSURANCE COVERAGE:
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1:0( OTHER TYPE OF INDEMNITY ❑ BOND ❑
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 ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
LLI 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 wit`Ii Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �''ii
PLUMBER'S NAME LICENSE#/467?-' . SIGNATURE
MP K JP❑ CORPORATIOONN?❑# PARTNERSHIP Oft Lc❑#
COMPANY NAME �Z�����`^"� ADDRESS —9/ CKS/ai+.rd
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CITY wQ.p� d'1�L� STATE �.jR' ZIP 0���3 TEL ��qr� (Z�
FAX ( CELL f / /2 ?? EMAIL_�ti2��1�OLt I'� UX l 1il Q�-f r
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
•
T 4'° COMM*NW LTH OF MA ACC USETTS
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFIT T ERS
ISSUES THE.FOLLOWING LICENSE I
MASTER PLUMBER ice
MOSES JOACHIM _g
301 BUCK ISLAND RD
W YARMOUTH,MA 02673
18677 05101/2026 605398
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER