HomeMy WebLinkAboutP-18-5927 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
31CITY Sorb(-{, YormnMA. MA DATE N/17 be, PERMIT#DOP/F iYY7
JOBSITEADDRESS S3 Sc)44, S-frc+ OWNER'S NAME TAnnt4.TL/(y 1
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALX
PRINT
CLEARLY NEW:❑ RENOVATION:5d REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r ; If 1 if II If I it
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM 1 i rf 1r r -II 1 r F
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DEDICATED GAS/01L/SAND SYSTEM r ,Ir �r r r ,r r I ;
DEDICATED GREASE SYSTEM I ,
DEDICATED GRAY WATER SYSTEM f it 1r r 7 .i , 1
DEDICATED WATER RECYCLE SYSTEM7. _ 1
DISHWASHER ii ,I �
DRINKING FOUNTAIN NM�, $ia
FOOD DIAPOAER
FLOOR/AREA DRAIN !1!!
INTERCEPTOR(INTERIOR) M,
KITCHEN SINK
LAVATORY 1
ROOF DRAIN 000
„SHOWER STALL SERVICE/MOP SINK ; ii it TOILETURINAL ;r �WASHING MACHINE CONNECTION ;� ;;
WATER PIPINGfWATER HEATER ALL TYPES r OTHER I 4 i
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if rr I _r it E i
Ir 1r Pr f ir f 7f r , ,r_ 1, l 1 i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
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: 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 a rate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in cam.' = al provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME James Pazakis LICENSE# 15030 Ad S IGN"Or
MP DI JP CORPORATION 0# C-3984 PART RSHIP❑# JLLC❑#
COMPANY NAME JM Pazakis Inc. ADDRESS 447 Old Chatham Road
CITY South Dennis STATE MA ZIP 02660 TEL 508-385-9127
FAX CELL EMAIL
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECT N NOTES
tkOk '�W / 'C Yes No • 9/iD/Il trio . 9
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THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT#
PLAN REVIEW NOTES