P-13-795 Iu _- L\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK --
s9 lilt CITY IJV+Nl9,w' o MA DATE 51f71)3 PERMIT# /9/9— 7
JOBSITEADDRESS G 6(2130 M}ctl an OWNER'S NAME Jan Dfl'1O3 I
POWNER ADDRESS IS1..Z ToW1ER- M Tev.AOBh1el TEL I7?-8,"..1-24,72— FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIALS
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:2 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 B 7 8 9 10 11 12 13 14
BATHTUB
i I
CROSS CONNECTION DEVICE 1 I s 1
DEDICATED SPECIAL WASTE SYSTEM I
DEDICATED GAS/OIL/SAND SYSTEM IIII
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEMEllin"
DEDICATED WATER RECYCLE SYSTEM I
DISHWASHER _
rL ,DRINKING FOUNTAIN 1IF1t^ JP • 1t , G
FOOD DISPOSER jJI _i_
1FLOORI AREA DRAIN I) 2' wINTERCEPTOR INTERIORIII ,l1;h NN; min
KITCHEN SINK 4WS.-1 11 1 w
LAVATORY r����_"`��`�iii ; ' 1
ROOF DRAIN I I r'-'1
pon
SHOWER STALL
SERVICE I MOP SINK l 1__TOILET I
URINALI1 I ;
WASHING MACHINE CONNECTION I i I _ I -_
WATER HEATER ALL TYPES ' , I 1
WATER PIPING II i I 1 1
OTHER r III I 1
1 1
1
1 I I i II i I ,
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 ❑ 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 a best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc with a rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 IGNATURE
MPQ JP CORPORATION❑# PARTNERSHIP❑# LLC 0#
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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