HomeMy WebLinkAboutP-14-705 cr` ^' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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Mr)l e CITY 10 )92M0 VW 1 MA DATE 0f/y 1 PERMIT# p/N--746—
JOBSITEADDRESS /6D geyV$w>z D IN yatt OWNER'S NAME letAke f pegRtw'
POWNER ADDRESS FF? TeD0(#1Aioa&i'y ifl1akIa 1 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL '
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:N PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB •
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CROSS CONNECTION DEVICE IK II I-11 II
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DEDICATED SPECIAL WASTE SYSTEM II
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DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM I
DEDICATED GRAY WATER SYSTEM t I I 1
DEDICATED WATER RECYCLE SYSTEM I I ll
DISHWASHER
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DRINKING FOUNTAINI II
FOOD DISPOSER _ _l _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I (1 I - I I
KITCHEN SINK I I I I
LAVATORY 1
ROOF DRAIN ,,
SHOWER STALL t t 1 I
SERVICE/MOP SINK I ( l
TOILET ) I I i
URINAL I I I 1
WASHING MACHINE CONNECTION ' II I 1
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BUILDING De.101,v1cn I INSURANCE COVERAGE:
I havrgyri rn'm4 nability-insuFence-policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ 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 ❑ 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 est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 NATURE
MPO JP CORPORATION❑# PARTNERSHIP❑# LLC0#
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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