HomeMy WebLinkAboutBLDP-19-002326 4/1
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
='I f= 4 CITY %PAN A\ MA DATE 101 1(n(L S PERMIT#h1Dfl7/�d M
JOBSITEADDRESS LQ 0t.\gtur Cov-e R-c1) OWNER'S NAME keS
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P OWNER ADDRESS ZP1 O04'0o Ccv-e. Q.cl TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL a
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:1K PLANS SUBMITTED: YES 0 NO❑
FIXTURES? FLOOR—) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM ,
DEDICATED GAS/01USAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
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FLOOR I AREA DRAIN
,�\1 INTERCEPTOR(INTERIOR)
\ter KITCHEN SINK •
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
`..? TOILET
(�V �U�R� INAL
�� WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I
WATER PIPING
OTHER
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INSURANCE GE:
gI have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i NO 0
IF YOU CHECKED YES,PLEASE INDICATETHETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LVU OTHER TYPE OF INDEMNITY 0 BOND 0
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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT 0
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to •- best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with a en • ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Spencer Hallett LICENSE#16224 I/
MP[ ' JP 0 CORPORATION❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME Spencer Hallett Plumbing and Heating ADDRESS 381 Old Falmouth Rd Unit 36
CITY Marstons Mills STATE MA ZIP 02R4R TEL 508-428-6080
FAX 508-428-7991 CELL EMAIL spencerrr allettphumbing.com
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