HomeMy WebLinkAboutP-14-695 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS I :get. noiti ret 9 ft f,.y. OWNER'S NAME Mg c /
P OWNER ADDRESS 6 e_. TEL Ao7-6JZl- -7.)-}FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ 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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BATHTUB ----1 - _
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CROSS CONNECTION DEVICE I I. I I II i I I
DEDICATED SPECIAL WASTE SYSTEM I 11 II I II II
DEDICATED GAS/01USAND SYSTEM . f II i U Il P _, I 1 I'
DEDICATED GREASE SYSTEM I P I t1 Il } � L II
DEDIl ICATED GRAY WATER SYSTEM I
DEDICATED WATER RECYCLE SYSTEM _ 11
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DISHWASHER If I II II I I 1
DRINKING FOUNTAIN C Pi 11 I I. r I
FOOD DISPOSER _ '
FLOOR/AREA DRAIN —� 1 -I 1 1 1 1 i 1
INTERCEPTOR(INTERIOR) l I I II IP I` I
KITCHEN SINK I I II I (1
LAVATORY I I P 1 _ I _ -
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ROOF DRAIN II I I I U
SHOWER STALL I-1 L �1
SERVICE I MOP SINK _ _.
TOILET
URINAL 1 ii I ti1, I U L
WASHING MACHINE CONNECTION 1' i 1 I 1 U U 6 I
WATER I!CATER AliL Tyr E p Il I I I I I 1 ii
WATEIRI''", —1I i i —I —I—II-1 ii
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uLILOItI T'�G.Ir .. INSURANCE COVERAGE:
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I have a wneht uabulty 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 a OTHER TYPE OF INDEMNITY ❑ BOND 0
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: OWNE f ❑ 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 • •: best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al .: anent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 IGNATURE
MPD JP E] CORPORATION 0# PARTNERSHIP❑# ac 0#
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