HomeMy WebLinkAboutBldp-19-003141 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS 77 t+EtaTJb.)E (191-'r_ OWNER'S NAME .THOiyes p>9save T7
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OWNER ADDRESS TEL __:FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL , RESIDENTIAL i
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CLEARLY NEW: RENOVATION REPLACEMENT:'-i PLANS SUBMITTED: YES , NO-
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r ,r- -I: ;
CROSS CONNECTION DEVICE I t I
DEDICATED SPECIAL WASTE SYSTEM ! ? r ii _.:. l.,- I
DEDICATED GAS/OIUSAND SYSTEM E. � ��ii ! _ I. ,, I '' I L �� ,
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DEDICATED GREASE SYSTEM ; " ., 4
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DEDICATED GRAY WATER SYSTEM `- L ,' ,1 _ jar i l'� 17 '
DEDICATED WATER RECYCLE SYSTEM i _ r ,� '� A i L a`y
DISHWASHER E - .. � ' _ '' . U _ .... .i.. , u. .0 it J
DRINKING FOUNTAIN _ # _, ; t 'r "IIII ��
FOOD DISPOSER I ,_ _�.__—. _ir—__ _ 1 t f- i
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NTERCEPROR(INTERIOR) r 'l J -1I-.^sc '' r__.__ }__ _
KITCHEN SINK �.. - It
LAVATORY >F 2- 1 it 1 a'I A
ROOF DRAIN 1 t i r- E L--. .v 1 ,
SHOWER STALL �y. _ ___ .___ _,f- "- !r__..-____- ;._ ._.�
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SERVICE/MOP SINK `f '' I _. _-2' 1,
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TOILET - L J -_, # r_ ._ __
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URINAL i l ' ---1 I----_ E -Jr- 1 . - r
WASHING MACHINE CONNECTION .. __�� �_ I ii �__--____ , _.. .'--. _ ,I I,,,, '
WATER HEATER ALL TYPES '6 ' i'- E
WATER PIPING ± —1 ii .r. r' ' 1 %,
OTHER i - —2_-i ---- ___-, z I 1�__ 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 - NO , .
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY F v 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 I
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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be' omplian with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( C� /9th C/foZ/12
PLUMBER'S NAME 1 David A.Whelan LICENSE# ,13046 SIGNATURE
MP1-31 JPL CORPORATION_ J#I (PARTNERSHIP �# 'LLC .,#e
COMPANY NAME I David A.Whelan Plumbing&Heating ADDRESS.67 Crawford Road
CITY;Cotuit "STATE' MA i ZIP "02635 TEL 774-238-2340
FAX I I CELL, 'EMAIL daveawhelan@gmail.com _
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