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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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_�°.i t CITY< f 71 4� �'' MA DATE/Z �2- PERMIT# 1* /i''-M3�
JOBSITE ADDRESS I,. Z) U-"Ev4-/L0 OWNER'S NAME II p LA.
POWNER ADDRESS i _.v b44 r ... .... �� T T .... _. AX
TYPE OR OCCUPANCY TYPE COMMERCIAL 71 EDUCATIONAL RESIDENTIAL', a
PRINT _
CLEARLY NEW:. RENOVATION: .. REPLACEMENT:4 PLANS SUBMITTED: YES` . NOR_
FIXTURES'1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB , 1
CROSS CONNECTION DEVICE '.
DEDICATED SPECIAL WASTE SYSTEM - i _ --Ir -71 1 ' ----7
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DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM imilimitionimmartmout , __
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _ t
DISHWASHER 1111011.1.11111111/1111., S
DRINKING FOUNTAIN
FOOD DISPOSER ONIUMNIMIRMIWININA
FLOOR/AREA DRAIN ;. ;MI
INTERCEPTOR(INTERIOR) IMIlliilIll.11iiiWMIIIIIINXIONIMII
KITCHEN SINK _
LAVATORY
ROOF DRAIN ;
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SHOWER STALL I
SERVICE/MOP SINK smionmaimamenniminissomman
TOILET
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URINAL
WASHING MACHINE CONNECTION i70
WATER HEATER ALL TYPES e 4 A .....
WATER PIPING ,
OTHER _
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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'i. NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING-THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ! 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: OW ER 7" AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicatio are true a accur to th est my knowledge
and that all plumbing work and installations performed under the permit issued for this application will in comp' ce with Perti ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I ANDREW LEIGHTON LICENSE# 16130-M _ - GNATURE
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MP JP CORPORATION 0#-3734C _ PARTNERSHIP; R# LLC
COMPANY NAME I HALL OIL COMPANY INC. ADDRESS: 435 RT 134 ;€
STATE
�_�� ZIP i 02660 TEL�
CITY SOUTH DENNIS . MA 508-398-3831
FAX 508-394-3068 CELL EMAIL (halloilcompany@rail.com
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