HomeMy WebLinkAboutP-14-252 I cis MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�1f=1 CITY pet&thil'f6(15— J MA DATE ID/td 115 PERMIT# PN---25
JOBSITE ADDRESS 124 f uNr Qa 2j49LT ?Q�OWNER'S NAME dr 1) C@i'if i'
P OWNER ADDRESS Sq/NAP I TEL 1113 plf4—[ 14 Y JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:10 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 1
DEDICATED SPECIAL WASTE SYSTEM t 1
DEDICATED GAS/OIUSAND SYSTEMI P
DEDICATED GREASE SYSTEM 1111:1111111
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DEDICATED GRAY WATER SYSTEM J II i, 1,1 E R l i
DEDICATED WATER RECYCLE SYSTEM l !''. p 1
DISHWASHER - - I. _.
DRINKING FOUNTAIN '
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FOOD DISPOSER - -- �LDINC1.3•-:27- l
FLOOR IAREA DRAIN1111.1111. s4 #T-fi1reZ illa
INTERCEPTOR(INTERIOR) I I i 11.1111PM, ,01
KITCHEN SINK l lr—1
LAVATORY ill il ;;
ROOF DRAIN (
SHOWER STALL . I
SERVICE I MOP SINK 1
TOILET
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URINAL I
1 i,
1 i WASHING MACHINE CONNECTION 1
WATER HEATER ALL TYPES 1 1 M
WATER PIPING i i ii i i I
OTHERp _i 6 _II f
1 I -1 � I 1
1 I I I I t I I II
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INSUF
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
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 ■ 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 - •- of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al P5,4 -• provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 ;0 i 'TURE
MPD JP El CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Checkoway 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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