HomeMy WebLinkAboutBLDP-16-004928 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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Wxs CITY/TOWN i L ! ► MA DATE 3�� MITa
ER # �3iPP-4-67,1/
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JOBSITE ADORES la
� a U OWNER'S NAME cd %��sk%Z.
P OWNER ADDRESS Pa "l�f TEL 731-42-91-11531 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCA 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR BS1.1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01L/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER /
DRINKING FOUNTAIN1
FOOD DISPOSER
FLOOR/AREA AIN /
INTERCEPTOR(INTERIOR) I I
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
_ URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES t
WATER PIPING
OTHER M
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BYCHECKING THE APPROPI ATEBC(BELOW
UABILITYINSURANCE POLICY ® OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WANER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the4
Massachusetts General Laws,and that my signature on this permit apprcaton waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that al of the details and information I have admitted or entered regarding this application are true and accurate to the t of
aro that all plumbing work and'nstallations performed under the permit issued for thisvrr
application wit be in complance al Parfi '7
Massachusetts State Pixnbing Code and Chapter 142 of the General Laws �`�
PLUMBERS NAME Dmitri Cha&e LICENSE# tat- —AL", •.
MP® JP 0 CORPORATION❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME Dmitri Chalice• ADDRESS 1378 Maki St f PO Box 304
CITY East Demis STATEMA
ZIP 02641 TEL 508294.8361
FAX 904218.0517 CELL EMAIL dmfriepseasidegasservice.arn
*For Seaside Gas Service,Inc-67 Helmsman Dr,Yarmouth Port,MA 02875-508.771-2768 fee -� e a,p scroYczat
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES