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C._ -• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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v r CINL GV,\I i-fzmayslj MA DATE 444(13 PERMIT# Pi0 /
JOBSITE ADDRESS 112 WtPA(3LCocr1 "DA_ OWNER'S NAME 6.e/tY 9, )cQ
P- OWNER ADDRESS 40 Spy Jr A aierw 441 O/iti I TEL 1Zti-ydd-.511a3 FAX
TYPE'OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:Q RENOVATION;01 REPLACEMENT:❑ - PLANS SUBMITTED: YES❑ NOD
FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS 1111.
DEDICATED SPECIAAN L WASE SYSTEM DEVICE �� .� � �
DEDICATED GAS/OIL/SAND SYSTEM ;aja'iM,IIIIIIII; : MI ISI(♦1♦,f(♦,IS
DEDICATED GREASE SYSTEM 1♦(♦rail NM1♦(♦(♦(♦1 (♦(♦
DEDICATED GRAY WATER SYSTEM ajai NMI I♦IMOM—i al a a, a a
DEDICATED WATER RECYCLE SYSTEM a li'n � tri��`_=�_ -
DRINWASHER _ �'K,a�,���, �_ '■�
DRINKING FOUNTAIN � , I I� ��_
FOOD DISPOSER I *paws.SFLOOR I AREA(INTINI 1 .11
INTERCEPTOR(INTERIOR) � � 111I��KITCHEN YINK � iM,a -i MLAVATORY �
ROOF DRAIN �I�,,�,—a-I I iS1,S1iS1,S1 a Slifl,
.ROWERSTALL r I i
ERVICE I MOP SINK
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TOILET
V WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES j -^ inn ^est
WATER PIPING 1 �
OTHER r
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IVt INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO ❑
'\ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE_ OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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3 LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY Q 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 est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway 1 LICENSE# 13417 IGNATURE
MPC JP CORPORATION❑# PARTNERSHIPQ# LLC❑#
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COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Road I
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1
FAX 508-385-6858 CELL 508-735.9993 EMAIL checkent@comcast.net I//l't% .G i 1 =' �1h
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