HomeMy WebLinkAboutP-14-388 .1 ...,,r
.t ... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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Mer� n MA DATE 2 Z 1 } PERMIT#114--388
JOBSITE ADDRESS 5 Wig -snt 'CcOWNERS NAME BILL LPtJG-
P OWNER ADDRESS S--A-MF TEL 5083$53609 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL a
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CLEARLY NEW:a RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 I l a 9 10 11 12 13 14
BATHTUB I I I . . L_ a i . I , I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM .1111SSai. I -_,__ I
DEDICATED GAS/OIL/SAND SYSTEM r ,I 11 I
DEDICATED GREASE SYSTEM ,
DEDICATED GRAY WATER SYSTEM -Mr la
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DEDICATED WATER RECYCLE SYSTEM a— IS I il j
DISHWASHER 1111 IS
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DRINKING FOUNTAIN 5"M rI i
FOOD DISPOSER I it I
FLOOR/AREA DRAIN WM I
INTERCEPTOR(INTERIOR) 1 ., 1
KITCHEN SINK '
LAVATORY
ROOF DRAIN
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SHOWER STALLSi
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SERVICE/MOP SINK
TOILET
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URINAL , _t
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WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES I
WATER PIPING r
OTHER q
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INSURANCE COVERAGE: '3 ..
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL 142. TES a NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND ❑
T R'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 0 AGENT 0
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 best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be In cpmpliance with all F�artin t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ / , e7 J
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PLUMBER'S NAME(William Poole LICENSE# 12879 f/V[^jf/J /SIIG ATURE
MPO JP CORPORATION a#2338C PARTNERSHIP❑# LLC❑# 9
COMPANY NAME Hall Oil Co.,Inc. I ADDRESS 435 Route 134
CITY South Dennis (STATE MA ZIP 02660 1 TEL 508 3343'1 C E I V E D
FAX 508.394-3068 CELL N/AEMAIL BBQ@CAPE.COM (�G uZ 7U� I
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