HomeMy WebLinkAboutBLDP-19-001331 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
„_ �`/33 3 CITY S YARMOUTH MA DATE 8/31/18 PERMIT 11,61/2P17-00/95/
JOBSITE ADDRESS 43 REFLECTION WAYS Y OWNERS NAME WILLIAM MACDONALD
P OWNER ADDRESS SAME TELJ FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:Q RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-• BSIA 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ,- - _
- - - - — - - -
CROSS CONNECTION DEVICE 2
DEDICATED SPECIAL WASTE SYSTEM -- - -- __ - --- --- -- -- — --
DEDICATED GAS/OIL/SAND SYSTEM --- -- --- - -- ---- --- --- ---- —
DEDICATED GREASE SYSTEM — -- --- --- -- --- — — -
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM ---- --- --- --- ---- --- -- ---- ---- -- — ---
DISHWASHER - — --- - - -- -- --- - — —
DRINKING FOUNTAIN ---- — — -- — --- ---- --- -- ---- ----
FOODDISPOSER - - _ _ __ _ _ __ - -- - - -.
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) -- -- -- ' - --- ----- ---- --- ---_- -- - --- -- --- --- ----
KITCHEN SINK — — — —
LAVATORY -- -- -,--
ROOFDRAIN -
SHOWER STALL I
SERVICE/MOP SINK
TOILET - - -
URINAL - --, - --- ---
WASHINGMACHINECONNECTION -- —
WATER HEATER ALL TYPES - - _ . _-- -
WATER PIPING — .- - , -- --- — — — -- -- —. -- ,----
OTHER - -- - -- - - -
/ I
1 INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑
j 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 ❑ <- NT 0
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 , - be knowledge
and that al plumbing work and installations pertonned under the permt issued nor this application win be in compliance wit , •�revtsion of the
Massactasetts State Plumbing Code and Chapter 142 of the General Laws. ��r
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 - •• .-
MP❑ JP CORPORATION❑ft; PARTNERSHIP EX JLLC[1#
COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo EU Rd
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508385-6858 CELL 503-735-9993 EMAIL checkent@comcastnet - _ .
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