HomeMy WebLinkAboutP-14-764 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS é l I c x eft. 0 14L7, I OWNER'S NAME CLAv 0 In(kr(An Tv-t _
POWNER ADDRESS rn,Allgrr0 a24l, il l,-•h,06V,-y OLEIC TEL A}–/f i FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL kr
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CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES NO❑
FIXTURES 2 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DEDICATED GAS/OIL/SAND SYSTEM �
DEDICATED GREASE SYSTEM _,_,_ ___,w•��I_WI_IM11__
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _r_1_i_110.11MI_j_I_I_IMO 1.1111111.1.1.1111,
DRINKING FOUNTAIN ME 1111.1t111111,1110.11111.111 I_C_■IM■1_l_l_i_li_i
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FLOOR/AREADRAIN II■111I,_G111111I1alU�1_I_:MS_INN MIMIIII*NMI NM,
INTERCEPTOR INTERIOR __1f_i1_'_01111i__i,_0.1._111■II10.l1111gU11111IC11111111I
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ROOF DRAIN 11.1. . 1
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SERVICE/MOP SINK __iai :,_(_I_IIII■I'_'II■1I■1111Iw1■!__I_i _t
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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 0 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 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 , ENT 0
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 the b-: • y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pert . ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 Spar`URE
MPQ JP CORPORATION❑# PARTNERSHIP❑# 1 LLC❑# .
COMPANY NAME Checkoway Enterprises ADDRESS 111 Scargo Hill Road niasincr. E
CITY Dennis STATE MA ZIP 02638 TEL 508-_385- i.
MAY 19 2D1 /d
FAX 508-385-6858 CELL 508-735-9993 EMAIL I checkent@comcast.net
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