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HomeMy WebLinkAboutBLDP-18-000499 661- 737- 6-3"6 C• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK RMOUTH 7 PERMIT# kr) CITY JO SITEAAD ADDRESS 33 KAYCEES WAY MA DATE 7/2OIWNER'S NAME GELLO KARYN R8 000499 P OWNER ADDRESS 44 SOMERSET LN NANTUCKET,MA 02554 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ ' PLANS SUBMITTED: YES❑ NO m FIXTURES 1 FLOORS—, ASM 1 2 3 4 5 6 7 8 9 10 11 12 , 19 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE _ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET _ 2 URINAL WASHING MACHINE CONNECTION 1 _ WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION' Ice Maker Connection INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m 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. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have subnulted 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 James Pazakis LICENSE*5030 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME James M Pazakis ADDRESS 158 WHITTIER DR CITY DENNIS STATE MA ZIP 026382400 TEL FAX CELL EMAIL ROOCII PLUMBING INSPECTION_NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES , r f ,A OK i'/IA7 Pte- Yes 0 THIS APPLICATION SERVE AS THE ^ T ^ y DCOISIT INT€ /. p { Vc FEES$ PERMIT# (71 tit o aN IIK`]t3jJ PGCT'/ 174 WO `1 . PLAN REVIEW NOTES inti mkt, jtry M S / /11 Ok_ NsvJ PC gift