HomeMy WebLinkAboutBLDP-15-003015 1 C MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS JI NH v4K5 IN%rfG && S i OWNER'S NAME 6eren-o P wM/
POWNER ADDRESS 6-04.-. e_ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:C' PLANS SUBMITTED: YES❑ NO❑
FIXTURES t FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE -11111111111111n1l11111011,111111111
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM __ _
DEDICATED GRAY WATER SYSTEM � I I II -
DEDICATED GREASE SYSTEM �I�I
DEDICATED WATER RECYCLE SYSTEM �f ,
DISHWASHER 1111-11111111.111111111111111,111—•
DRINKING FOUNTAIN
FOOD DISPOSER iIMAM IMO II II ;MiS55MI;5I
FLOOR I AREA DRAIN I
INTERCEPTOR(INTERIOR) II,nini t' 'I I�,s��_�
KITCHEN SINK �I —I 1 7Ali�I,�I—I �!�'.
ROOF DRAIN1LAVATORY 1111111test
SHOWER STALL
SERVICE MOP SINK RRRSRRR•IR,RR•SR
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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 D NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY 0 BOND El
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
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to : •est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit• all P• ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 if ATURE
MPD JPO CORPORATION❑# PARTNERSHIP❑# LLC 0#
COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Road
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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