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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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$t_jg CITY S . Yil/l.M6 vlli MA DATE 7 % /i j PERMIT# &-a)16_a2:)p2ii7
JOBSITE ADDRESS I O j i,, ff t J;y. OWNER'S NAME jwi V Pe eetiqJL.f-
POWNER ADDRESS I'd T/111.-y a (52(4471}etQtQ O)JTh TEL)7q 01- -!3 3p FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL n RESIDENTIAL'
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:LEI PLANS SUBMITTED: YES❑ NOLI
FIXTURES 1 FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB U U U U U U U U U U U I I
CROSS CONNECTION DEVICE U U U II IIU U U U __._ I
DEDICATED SPECIAL WASTE SYSTEM ; U I U U U U U _,_1_,.___ I
DEDICATED GAS/OIL/SAND SYSTEM I U U U U U U U U U U U I _--_.--
DEDICATED GREASE SYSTEM U U._ U U U I) - U U U U U I v- I --
DEDICATED GRAY WATER SYSTEM ' I U 11 II 1 _ U U U U
DEDICATED WATER RECYCLE SYSTEM ' U U U _U U 11 II___.__U U II _lf____
DISHWASHER U U U U U U U U U U U U U
DRINKING FOUNTAIN U U U U U U U U U U U U U
FOOD DISPOSER 11 11 11
FLOOR/AREA DRAIN U _ U U II 11
INTERCEPTOR(INTERIOR) 1 11 _ JJ U U ..0 11U U U U U u U U
KITCHEN SINK U _.. U U U U U . . ,.U_.......U U U -U___ ..U
LAVATORY .._.. U U U U
ROOF DRAIN U U U U 11
SHOWER STALL 1 U I. U U U U U U U U U
SERVICE/MOP SINK U U U U U U U U U U U U
TOILET i
1U U 0 U U U U 0 0 1 U U
URINAL I - _U U U U U U U U U U U U
WASHING MACHINE CONNECTION I U II -._,_-II
U U U U U U U
WAT.' i,. , C,TYPES =: 1 M -/ U II U - J— I .II U. # U U U U_
WAT:R ►i. . , ii 11
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i INSURANCE COVERAGE:
I have a current lia�ty 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 ❑ BOND Q
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 ❑
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 accur to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 IGNATURE
MPH JP❑ CORPORATION # PARTNERSHIP' I# LLC #
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