HomeMy WebLinkAboutBLDP-25-832 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY RA)e' r (NV, MA DATE IyAI 3 7.1ya. PERMIT# ("52
JOBSITE ADDRESS /S- Den/V6W- G27 iJo' OWNER'S NAME C N t - L E e
OWNER ADDRESS UN i T �- y TEL SU e zee i✓y/a j FAX
j
TYPE OR OCCUPANCY TYPE COMMERCIAL I I EDUCATIONAL I. I RESIDENTIAL
PRINT
CLEARLY NEW:U RENOVATION: REPLACEMENT:;!>-K PLANS SUBMITTED: YES NO[
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 11 IIIi _ C 1
CROSS CONNECTION DEVICE t
DEDICATED SPECIAL WASTE SYSTEM ( 'I (h u, 11,. . I
DEDICATED GAS/OIUSAND SYSTEM 0 11 11 __ 11_
DEDICATED GREASE SYSTEM I ir Ill
DEDICATED GRAY WATER SYSTEM 11I -
DEDICATED WATER RECYCLE SYSTEM ( I. l ;j 11 t I,
DISHWASHER I t I I
DRINKING FOUNTAIN ; I 0 11 11.
FOOD DISPOSER '
FLOOR/AREA DRAIN I ..
INTERCEPTOR(INTERIOR)
KITCHEN SINK II_ 0 I J
LAVATORY
ROOF DRAIN • I
SHOWER STALL ( .., I
J
SERVICE/MOP SINK ) } I ' # t< 1
TOILET I I --
URINAL f t 1NA 0 ,20 0
WASHING MACHINE CONNECTION I I ,, 1
I I
WATER HEATER ALL TYPES __ 1 _ I I I
WATER PIPING I_ I 1 � DE ,AR T��NT 1
OTHER A[ S�6t1t -
I I I
II II Il I I 1
i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESa No El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY I I 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 ,J AGENT Li
SIGNATURE OF OWNER OR AGENT
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.
PLUMBER'S NAME i,) �^ 1�tan• LICENSE# I z I SIGNATURE
MPf JP❑ CORPORATION # PARTNERSHIP #1 LLCIJ#
COMPANY NAME FT---3/4- }!r S ,,t c t t o ADDRESS i r 3 (iv.-%T 'to v9 1
CITY (N' i IA/044.4.,tm STATE m ZIP 02 T-7 G TEL TJ E. 724 /(iv S—
FAX CELL 77), ye7 EMAIL 11'/s.�,,ti-j 3 3 0 (i7 - 6 y,
c7o (i#
GVAI &
MASSACTIOS
F aillAle,gyp
1;4 i4
RII[444L�sl "1i 'I�=
Ici�d n oil
4 afi ✓ ''
Fr
I�III a w C—.,0'�
1{EY#&&y II
10 88A M 14EEX I5.49I! f
8 001E04 0028 Rev 0828/8018
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
rI: ISSUES THE ---AJkOWING LICENSE
MASTER PLUMBER
-IILLIAM O HEATH JR
153 COUNTY RD
WEST WAREHAM,MA 02576-1508
1_
� s
12021 81011002026 607257
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
,', •, • t •.F ,i ' a.' a 41
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLIJIyBilERS AND GASFITTERS
I_ 0$191ING LICENSE
�19uu I RIIwI'
+PLU ER
,turiAm O ligATH JR tsw p
11
COUNTY
. I III ,��,
,NAREH, ,MA 02576-1508
231189 606116
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER