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HomeMy WebLinkAboutBLDP-19-000192 — I ..A.A. ' Il1/1Y V,ii7V'JL.I IV Vint y•m•spa . ...�..._�__ .. _ _ s- CITY` l `-'�`"-- I MA DATE 1 ^7- 1- a-o l81 PERMIT# P l9--ao6/9z 1 y' ►— OWNER'S NAME *v—{' JOBSITE ADDRESS i kS �cz,�wz.c� � � - OWNER ADDRESS I I TELj IFAX i� TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Q RESIDENTIAL E PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:[� op44112,-)i PLANS SUBMITTED: YES❑ NOD FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14Y BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01USAND SYSTEM DEDICATED GREASE SYSTEM f_ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHERY DRINKING FOUNTAIN I FOOD DISPOSER FLOOR/AREA DRAIN — INTERCEPTOR(INTERIOR) ` KITCHEN SINK I I LAVATORY ROOF DRAIN SHOWER STALLt , SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES WATER PIPING OTHER — um am, an nisi as am um mi awe aut aim 11111111 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0 ` IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY E3 BOND Ej 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 0 AGENT Ej SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this appt' n are tie a • .• rate • ••= of my know!€ge and that all plumbing work and installations performed under the permit issued for this application ' be in c o$plia •- all,_ •rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L- PLUMBER'S NAME Chris Holcomb LICENSE# 11609 / SIGNATURE MPQ JP0 CORPORATIONQ#3586 PARTNERSHIP❑#I 1 LLCp#I COMPANY NAME David Holcomb Plumbing&Heating Inc ADDRESS P 0 Box 170 CITY Osterville STATE MA ZIP 02655 TEL 508-420-0077 FAX 508-420-0036 CELL 508-326-5598 EMAIL Chris©holcombplumbing.cam 1 i.. 4t 64 6rt �o� �� 4 I Y � I N -1n � e;