HomeMy WebLinkAboutP-14-679 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
gr;" atvishrit CITY W•VIQ�IVl(�I MA DATE f"f,'4' PERMIT# 479
JOBSITEADDRESS tP Aiden 94- 2ilkbti 3,77 OWNERS NAME
P OWNER ADDRESS 3 1.1,..s,.....L( - • . :ala TEL 7ff/ R-57/6 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL K
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑
FIXTURES t 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
r Iw
WTI g 171 �
0 HE C,[!)#3//S6 0
. PR 16201'#
2,in nimr.n ' IMENT
Dy: i7 _ I INSURANCE COVERAGE:
I have a current fbfl
ai msuranc6 policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES N NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
, UABIUTYINSURANCEPOLICY 51 OTHER TYPE OF INDEMNITY 0 BOND ❑
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.
CHECK ONE ONLY: OWNER 0 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 th= •est of my • ledge
and that at plumbing work and Installations performed under the permit Issued for this application will to in compliance with at Pa visi'
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '`,I.. �j
.f'� IA
PLUMBER'S NAME Dmitri Chalke LICENSE# 10322 ' SIG'"••E
MP® JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME D. Chalke ADDRESS 6 Sassafrass Ln
CITY Harwich STATE MA ZIP 02645 TEL 508-294-8361 -
FAX 774-994-8459 CELL EMAIL seasidegas@comcast.net
ROUGH PLUMBING INSPECTION NOTES BELOW IT)R OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPUCATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMITS
PL%N REVIEW NOTES
•
•
•
r