HomeMy WebLinkAboutBLDP-20-002089 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,- girl®,i CITY >/4 c vT?-1 1 MA DATE PERMIT#,Pp��°
JOBSITE ADDRESS ,• 4,4„ A w 4,_ Q tit OWNER'S NAME C 6nr"r ck
OWNER ADDRESS ,.__., . _____ _ ,�..... TEL ',._ FAX J
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:Q RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES[Q NOD
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ,.,.- i.. __ -, L I . I .. .__1
CROSS CONNECTION DEVICE intiMiiiiiiiiiiinsimitiiiii •, [ f -
DEDICATED SPECIAL WASTE SYSTEM ,
DEDICATED • - __iuumarwarili. , ,,, arminuilli,
i
DEDICATED GREASE SYSTEM ; —a .1E ':—ice
DEDICATED GRAY WATER SYSTEM IIIIIIIWIIIIIIF.IWI I MEWL
DEDICATED WATER RECYCLE SYSTEM __ !____ `-__ EMI RE
DISHWASHER I � .
DRINKING FOUNTAIN -'
FOOD DISPOSER
1��.�- (�_�I!CLI�i��: �1�1�11i_�llllllllf I i111i,i111 ,
FLOOR/AREA DRAIN IOIINRWIIIOIJIONIIMAIIIIIIIIIIKIOIIISIIIPIIIOIIIIIIIIIIIIIIIIIIMIIIAOIII
LAVATORYKITCHEN SINK illiW
r ! i ( Arm-mg
ROOF DRAIN
SHOWER STALL
WASHING MACHINE CONNECTION111111.1111.011.1101111110101.31111111110.110111.1•1110111.111111
WATER HEATER ALL TYPES111011-111111.0.1-011.10.1111.101111.iiiiiiiiiimliiiiiiitiailiniiiii
WATERf III
OTHERiiiingiste, nziow.P2
.1.I III
.1 __ow MN
E.,..,e_»__ _,„„, _.,_ ____ __ _ L „.,_- �. ;.. __,. . . iL- _ I __ a _, .,, . 'i ,,�-_ W_ , _,_..
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO D
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND D
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 i ONLY: OW, R it AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ar tr and ac to o th-bes of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will b '•mp;.:„0:1"..-I - •ert' nt p'.vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
ANS S..
PLUMBER'S NAME .Dennis M.Devine__.._______.._-_ - ,.,___.•„_wILICENSE# 11741 _ , —"♦ I A'-
�'E
MPD JP CORPORATION['#_2931_ IPARTNERSHIPD# ILLCD#
Plumbing&Heating,Inc. ADDRESS 8 JanSebastian Drive,Unit 23 .
COMPANY NAME Devine -..n,-� .. _.u _.- . v e ._.
CITY Sandwich I STATE MA ZIP 02563 i TEL 508-888-9002
FAX 508-888-8313 CELL 774-392-1741 °EMAIL dennis@devine-plumbing.com I
cc)* i j 201r
� O
S N