HomeMy WebLinkAboutP-13-830 • , _-... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ac:" r'
i?� C CITY Iw -Y13(ono ufl) I MA DATE' 51361)3 1PERMIT# Pl3- Ste'
JOBSITE ADDRESS IN r/a,v& '- ( e4 OWNER'S NAME WAyr42 I'Wdp (I
P OWNER ADDRESS It OTIErg. Ci 5-(tent J M9- 0)t(1"1, TEL 9)( c/ff-5 ? FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ - RESIDENTIAL
PRINT
CLEARLY NEW:ID RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES El NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 i 13 14
BATHTUB ( (C T 1 171�_ 1 11` 1 T 1 1
CROSS CONNECTION DEVICE ;
DEDICATED SPECIAL WASTE SYSTEM 1 1 1 I 1 t
(
DEDICATED GAS/01USAND SYSTEM -- _ ( I ('
DEDICATED GREASE SYSTEM I ( (I I
DEDICATED GRAY WATER SYSTEM ( I ( (I if ( I
DEDICATED WATER RECYCLE SYSTEM -`l ri 1$I IIDISHWASHER 7 t 1
DRINKING FOUNTAIN ( ( 1 1 (\\\ (
FOOD DISPOSER
I ('��
FLOOR/AREA DRAIN —
t 1
INTERCEPTOR(INTERIOR) ; �_j
KIT 11
TCHEN SINK
LAVATORYiL i
ROOF DRAIN 1
SHOWER STALL i ( ( ( (
SERVICE/MOP SINK l _ (, )
TOILET -j
URINAL I II, ( I
WASHING MACHINE CONNECTION I ll i i i 1 I ��
WATER HEATER ALL TYPES I j
WATER PIPING i i (
OTHER I I .. I_ 1 l 11 ii _ + 1 I ( .
( I 1. I
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES D NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D 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 the of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pert rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 ATURE
MPD JP E] CORPORATION❑# PARTNERSHIP❑# LC 0#
COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Road r,
_ i,)t ir1
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1 111fll(
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net JUp JUI? H LOB U)
L`^ L"' 1 u...1�. T
By I r-