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1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS (I( L.,'far__ Lire.- OWNER'S NAME (,o)r, e OCt. d
POWNER ADDRESS SA„+.fj TEL 5C 9;r5 —I c615FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E
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CLEARLY NEW:PA RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i L __ I 1 ; II I
CROSS CONNECTION DEVICE I , V I i
DEDICATED SPECIAL WASTE SYSTEM 1 j I,
DEDICATED GAS/OIL/SAND SYSTEM J II __ , I I. I. _ 6 _.
DEDICATED GREASE SYSTEM I I I I I
DEDICATED GRAY WATER SYSTEM I L , [ i.
DEDICATED WATER RECYCLE SYSTEM i i I ,
DISHWASHER 1111 II 'I. I
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FOOD DISPOSER ( II,
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DRINKING FOUNTAIN
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FLOOR/AREA DRAIN ,�I I '
INTERCEPTOR(INTERIOR) ( IR
II II
KITCHEN SINK
LAVATORY I ,, , I
ROOF DRAIN I
SHOWER STALL Ii111 III 11 I i
SERVICE I MOP SINK ! ii,
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TOILET 1
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URINAL I i mutt
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WASHING MACHINE CONNECTION II I R ,. "' .
WATER HEATER ALL TYPES - I II 1, S 2
WATER PIPING f II I I I II 1 II .I
OTHER [ ,,, II_ I, �i ;I_ xi; r�. -u nArndi _
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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 Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q , 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 %I 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 - .est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance w'h all .- •-nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway • LICENSE# 13417 S s `TORE .
MPD JP CORPORATION❑# PARTNERSHIP❑# LLCD#
COMPANY NAMECheckoway Enterprises ADDRESS 11 Scargo Hill Road
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net •
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