HomeMy WebLinkAboutBLDP-17-003474 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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. PERMIT# OP"I7. 49
/.iti/: CIN cOevV-eitA 1-1 MA DATE
JOBSITE ADDRESSet-Y�� G V-e- OWNERS NAME
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C.S C/V _
OWNER ADDRESS _.. ...... :; TEL 31?.$S 2 S _...FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL _,,. EDUCATIONAL _, I RESIDENTIAL•)C
PRINT • 1�
CLEARLY NEW: . ' RENOVATION: REPLACEMENT: k PLANS SUBMITTED: YES NO_ -•
FIXTURES 7 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) A '-
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
.SERVICE/MOP SINK
TOILET'
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 4G1
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 , NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ' OTHER TYPE OF INDEMNITY i 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 accurate • •. t of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in coy- •• a P-•: -nt provi '•n of the
Massachusetts State Plumbing Code and Chapter 142 of the General taws.
—41
PLUMBER'S NAME••TIM MCELROY I LICENSE# 15993 4 ' r ' URE
MP:.„ JP ; CORPORATION # PARTNERSHIP .._;# LLC #.
COMPANY NAME CAPE COD MASTER PLUMBERS,INC. I ADDRESS:70 CRANBERRY HWY P.O.BOX 756
CITY SAGAMORE I STATE MA ZIP 02561 I TEL'508-3175525 j
FAX CELL i EMAIL , /