HomeMy WebLinkAbout BLDG-26-129 i
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ilbilR.cutQ-Ll,A MA DATE ellZ/?.G PERMIT##& '2 -aay
JOBSITE ADDRESS R4TTnt es�1�^t/e OWNERS NAME CL' 'N5 G-S-A/E
POWNER ADDRESS Lr-6 4Q91-Iv4 S /TV.e TEL7754..248/?.�/L FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL E
PRINT
CLEARLY NEW:0 RENOVATIONS, REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1 FLOOR 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14-
BATHTUB t
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/AREA DRAIN
INTERCEPTOR(INTERIOR) - - -
KITCHEN SINK I 7 -
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
I TOILET R E C4,
URINAL - - - r-_ = -. -,
WASHING MACHINE CONNECTION - I
WATER HEATER ALL TYPES • FEB 12 ga
WATER PIPING _
OTHER BU LDING D ,.R i f;.,
T
INSURANCE COVERAGE: 1
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 POUCY OlY 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
j Massachusetts General Laws,and .t m signature on this permit application waives this requirement.
i
- /' ' CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATUR ,/F OWNER OR AGENT
LU 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 thepermit issued for this application will be in compliance with all•erlinent provision
PP P n of the
P
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /i
PLUMBER'S NAME Azcz. 5 .Zict,C9ru-N - LICENSE#ice?- - I NATURE
MP P4 JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME 1Yltlas%1 fet�wimp,1}P � ADDRESS 30I �c k ICI rt,.+ot 2�
CITY LA.)�s'f 1 A,1'>nn p STATE NA-- ZIP o -C*3 TEL/1?- 51-as 112 7z
FAX CELL 3-?/f -91 (2$2 EMAIL rYI4 OCA15' 4-aG-h/G4A.CaY✓)
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
--"g7-7-C•Mao NWEALtH OF ItiA A HUSETeS
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
MASTER PLUMBER
I ti
MOSES JOACHIM
10
c 1--
301 BUCK ISLAND RD
W YARMOUTH,MA 02673
S).
18677 06/01/2026 606398
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER