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R1' ` .o._A—k- . 1 MA DATE R-a).-19 1 PERMIT#da -/F-10J5
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JOBSITE ADDRESS � � NAME� _•-�---�
P OWNER ADDRESS I TELL —J FAX 1 !
TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL 0 / RESIDENTIAL[PRINT (
CLEARLY NEW:Er RENOVATION:❑ REPLACEMENT:n Iyh I(e I(D PLANS SUBMITTED: YES 0 NOC✓
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
_DISHWASHER
DRINKING FOUNTAIN 1IIII ma Er_Rio on 4 N-
FOOD DISPOSER
FLOOR I AREA DRAIN f
INTERCEPTOR(INTERIOR)
KITCHEN SINK
I LAVATORY 2 .
i ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK 1
1.TOILET
URINAL
WASHING MACHINE CONNECTION -
WATER HEATER ALL TYPES
r WATER PIPING
OTHER
O.-A b oa"-LA-can,\....-S1.Ly tr.J ( J r
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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 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
I
LIABILITY INSURANCE POLICY 2 OTHER TYPE OF INDEMNITY[J 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: OWNER n AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application true and rate to the best of my knowledge --
and that all plumbing work and installations performed under the permit issued for this application will in lie ce 311 Pert on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Chris Holcomb LICENSE# 11609 SIGNATURE
MPRJ JP❑ CORPORATION Q#3586 PARTNERSHIP[]# ILLCD1I 1
COMPANY NAME David Holcomb Plumbing&Heating Inc ADDRESS P 0 Box 170 II+- 4-
CITY Osterville STAT ZIP 02655 TEL 508-420-0077 �sl
FAX 508-420-0036 CELL 508-326-5598 EMAIL Chris@holoombpiumbing.com Mr .) /Ij1
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