HomeMy WebLinkAboutBLDP-19-002654 g: , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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j -'-R_ /CITY 4114. J MA DATE I1O I24 IPS IPERMIT# &'JQ dO&(0
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iivp. JOBSITE ADDRESS 2 5aedi 1r•L i OWNER'S NAME I eQjlan cp.o
P OWNER ADDRESS keMS'"� 1�2�eo_fe�f W c I pQ1 t _I TEL co: • ..5• 2 FAX-'
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL LI f RESIDENTIAL
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CLEARLY NEW: ] RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOR
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB g1 1 r f` ir r _
CROSS CONNECTION DEVICE ' f •j !
DEDICATED SPECIAL WASTE SYSTEM , 1 + i 1, ' I.
DEDICATED GAS/OIUSAND SYSTEM ', j '
DEDICATED GREASE SYSTEM
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DEDICATED GRAY WATER SYSTEM ' ' r
DEDICATED WATER RECYCLE SYSTEM , r f I i _.
DISHWASHER �' ' 1� •
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DRINKING FOUNTAIN f
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) l ',F n
KITCHEN SINK
LAVATORY 1
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ROOF DRAIN j j
SHOWER STALL r j ` i 9111111 SECE/MOP SINKf1I
URINALAmilaranIj�ri4j�� ,. - NOLial
WATER HEATER ALL TYPES Sir ,�1�JjM ��jilit
WASHINGMACHINECONNECTION S , ^r
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WATER PIPING F •
OTHER BACK FLOW u rin .
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 0 OTHER TYPE OF INDEMNITY 9 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 0 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 to the best of my knowledge
and that all plumbing work and installations performed under thePermit issued for this application will be • •• q -nce .th all Perti - t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Frank,W.Roderick !LICENSE# 7794 SIGN•TURE
MP0 JP® CORPORATION 0# 1762-C PARTNERSHIP®# . LLC®#Ma
COMPANY NAMEI Rustlls Inc. I ADDRESS 1222 Mid-Tech Drive
CITY West Yarmouth J STATE MA ZIP 02673 I TEL 508-775-1303
FAX 508-771-9310 CELL - EMAIL nick.rus sinc.com
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