HomeMy WebLinkAboutBLDP-15-002096 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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11471 CITY S,yo49-0CN10fl} j MA DATE niWI&a PERMIT# GL.GJRNO
JOBSITE ADDRESS 11 eve9. &EC") or 5.• OWNER'S NAME Mit 6/ ewe &CFFO I
P OWNER ADDRESS '( SCMvy(dnJJv P r41g-tw k- TEL 014 i 754/-0,1b I IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL&
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:W PLANS SUBMITTED: YES❑ NOD
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 67 8 9 10 11 12 13 14
BATHTUB -
CROSS CONNECTION DEVICE 7
DEDICATED SPECIAL WASTE SYSTEMmintip
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
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DISHWASHER _ _._ __
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
1‘11111KITCHEN SINK
LAVATORY
ROOF DRAIN I
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL 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.142. YES a NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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 tot st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit all e t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 719 URE
MPQ JP • ' CORPORATION❑# PARTNERSHIP❑# LLC❑#
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