HomeMy WebLinkAboutP-14-440 .- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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Jklg C CITY I S t yerzflio VIII- i MA DATE 12.924/13 (PERMIT# Rig— Ya
JOBSITE ADDRESS 2.,D._ Ze-tsvod o Rd Sy. OWNER'S NAME ,ren_ C9,1f(/4
POWNER ADDRESS S'Otry C TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATIONS REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 1 1 1. .. 1 �� -1,---R
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CROSS CONNECTION DEVICE j
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN I
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) R
KITCHEN SINK i ,
LAVATORY
ROOF DRAIN SHOWEER STALL 111.11111
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION ,.
WATER HEATER ALL TYPES
WATER PIPING
OTHER _ Sil
1 ' !qt 17 ,5 , t1 ' II-
INSURANCE COVERAGE: 1 ( - _ I'
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG (1.142. YES Q NO ❑ Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW U
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LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY ❑ BOND El By GFCElS_t/9- _k.
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the D 7150
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 est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al P ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 IGNATURE
MPD JP CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Road
CITYrDennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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