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HomeMy WebLinkAboutBLDP-19-003143 I SC • e , MASSACHUSETTS�� I1UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGnWORK '/ 11 t CITY £4 ,. ilitalt ( "[ 6 I MA DATE / PERMIT# P//)P/7'Cb'/4f9j JOBSITE ADDRESS /7 (i ch/re Col OWNERS NAMEI 4 Le ec Iv 1 P OWNER ADDRESS TEL got(Q5/77t1 FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL0 E l IO` [0 RESIDENTIALVZ PRINT CLEARLY NEW:0 RENOVATION:Q REPLACEMENT:® p1'PLANS SUBMITTED: YES® NO© FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 I 9 10 11 12 13 1 14 BATHTUBNIS .MIIIIr IP CRCONNECTION DEVICE - SS IIISSIAS mpg O — -SPECIAL ASESYSTM r— -- Iw' DEDICATED SAILIS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 0.110ant - DISHWASHER - _- 1♦ DRINKING FOUNTAIN SI,l , ,,,,. r •- 1 FOOD DISPOSER FLOOR/AREA DRAIN I — INTERCEPTOR(INTERIOR) ,,,,. .A.w KITCHEN SINK LAVATORY _ _ ROOF DRAIN , SHOWER STALL : - - r------ --— ...._ --_ _- - _ _ TOILETE I MOP SINK URINAL WASHING MACHINE CONNECTION _ i_; tit. - WATERHEATERALLTYPES i WATER PrIPING OTHER I V. - .. C --. - ---,I IIIIAII ` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142. YES Q NO Q • IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY Q BOND OWNER'S INSURANCE WAIVER:lam 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 Q AGENT Q 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 mpliance with all Pertinent provisi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !1 , PLUMBERS NAME Craig Bishop J LICENSE# 15101 s SIGNATURE • MPO JPQ CORPORATIONQ# PARTNERSHIPQ# i LLCD# COMPANY NAME High Efficiency I ADDRESS 378 Route 130 3 CITY Sandwich ii STATE is Ma ZIP 02563 1 TEL 1508-825-3695W i FAX j CELL EMAIL admin@high-efficiencyllc.com , . _, . co - - " LP# , e0rw ?yen