HomeMy WebLinkAboutBLDP-15-003236 C y ,
1, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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I MA DATE 1 2 -7 —/y I PERMIT#aWo —�n3�3/o
JOBSITE ADDRESS 1 1 /32Er✓STt(L ✓ZOAY) ( OWNER'S NAME 0Pfr1 13E4uaG (
P OWNER ADDRESS �ll.MI! I TELLcPR777/.74I (FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL G
PRINT
CLEARLY NEW:a RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO0
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I I I I i r I( I II I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM F I I i I r ( r I i
DEDICATED GAS/OIL/SAND SYSTEM I 1 I 1I r
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM F l 1
DEDICATED WATER RECYCLE SYSTEM : r I ( I I
DISHWASHER ( I I
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FLOOR I AREA DRAIN IuhIiiiIinhIi r _ _ r
FOOD DISPOSER ��--- I, r DRINKINGFOUNTAIN INTERCEPTORINTERIOR KITCHEN SINK
OOF DRAIN ��eaa� r�SHOWER STALL S _flI] ifl SF if111•'
SERVICE/MOP SINK
TOILET _
URINALI- (.
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WASHING MACHINE CONNECTION F ,I i J r
WATER HEATER ALL TYPES
WATER PIPING �'I I [ ( ( 1 , '
OTHER I BA-c_Kt' I
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INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.1 2 - t j:�F
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 26 Its p U"
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND❑ DEC 02 2:::4
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the Insurance coverage required by ha Uer4Ict0PA 2.Tr....t. J
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Massachusetts General Laws,and that my signature on this permit application waives this requirement. By
C K ON' • ' . OWN R ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT /
I hereby certify that all of the details and Information I have submitted or entered regarding this awl; on a - r= •accurate he of tmy knowledge
and that all plumbing work end Installations performed under the permit Issued for this application will bei. t• an e with : - nent problon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / s�
PLUMBERS NAME Andrew Leighton (LICENSE# 16130-M SIGNATURE
MPQ JP❑ CORPORATION a#2338C PARTNERSHIP❑# LLC❑#
COMPANY NAME Hall Oil Co.,Inc. I ADDRESS 435 Route 134 (
CITY South Dennis ISTATE MA ZIP 02660 ( , TEL 508-398.3831 I
FAX 508-394-3068 CELL EMAIL HALLOILCO@YAHOO.COM ilCht