HomeMy WebLinkAboutBLDP-19-001554 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK.
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JOBSITE ADDRESS l arc,/+ •. ' OWNERS NAME ep - g -. es C Q
P OWNER ADDRESS: / -- •-•_. . . — .._:_. :.. -. -- . .._ _ . :F . ._..-
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TYPE OR OCCUPANCY TYPE COMMERCIAL . EDUCATIONAL ° " RESIDENTIAL:
PRINT _
CLEARLY NEW:; ' ' RENOVATION: REPLACEMENT< PLANS SUBMITTED: YES. NO
FIXTURES 1 FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB . • . . . • .
CROSS CONNECTION DEVICE ( _
DEDICATED SPECIAL WASTE SYSTEM ...
DEDICATED GAS/OIUSAND SYSTEM •
DEDICATED GREASE SYSTEM - ' -
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM • • • •
DISHWASHER -
DRINKING FOUNTAIN - -
•
FOOD DISPOSER • "
FLOOR/AREA DRAIN .
INTERCEPTOR(INTERIOR) _ _ '
KITCHEN SINK .. •
LAVATORY .
ROOF DRAIN -
SHOWER STALL - -
SERVICE/MOP SINK _ _
TOILET -
URINAL _ _'
WASHING MACHINE CONNECTION - - -
WATER HEATER ALL TYPES
WATER PIPING - • '
OTHER • -
•
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 7; NO ' •
If YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW .
LIABILITY INSURANCE POLICY•4. - 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 1 -
.1 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 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. .' /\ 4 L Ce t
PLUMBERS NAME•Mark Couto LICENSE# 15656 � SICGNNAATURE
MP.' JP . • ' CORPORATION-•• # 3408 PARTNERSHIP # • ••LLC'• • #
COMPANY NAME Mark Couto Plb&Htg Inc_ ADDRESS 1103 Lake Shoe Dr •
CITY:Brewster STATE. MA :ZIP 02631 ' TEL 508865.2145 '
FAX 508896-2577 j CELL: - ;EMAIL .Markjcautojyahoo.eom
REC -FrIV-EC
SEPi3 2018 J 62b
BUILDING DEPARTMENT
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