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. .r--- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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tfr Mb 514f1/24-. J MA DATE al 4,b3 PERMIT# ,P/9- ca
JOBSITE ADDRESS /Y C(LAC_ Eli Yy r OWNER'S NAME Lig +/2(Q, DAY 10
P OWNER ADDRESS fern-- . TEL Jz- G r-/c6r FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:' RENOVATION:❑ 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 —11 11111
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ,
DRINKING FOUNTAIN
FOOD DISPOSER 11111
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) j
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION WATER HEATER ALL TYPES iWATER PIPING OTHER r i i
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INSURANCE COVERAGE: /in -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG jI1p SQ.142. ,YE .,NO ❑L
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO .
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LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY ❑ BOND❑ Ey (–ft- js30.,�
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the S 02
Massachusetts General Laws,and that my signature on this permit application waives this requirement. LiCh
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 be/my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe,i — on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / X
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 SI s" RE
MPD JPD CORPORATION❑# PARTNERSHIP❑#MEM LLCD#
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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