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HomeMy WebLinkAboutBLDP-19-005119 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO PERFORM PLUMBING WORK =�__► � CITY #12-MPAK-thMA DATE g f // 1 PERMIT#, ,—Dr—6/6 57/? JOBSITE ADDRESS 20 0011k.. 'Sr OWNER'S NAME 4k-ce- • OWNER ADDRESS 40-1.0 S-r Cv.).‘kiat4 L FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL IAL CLEARLY NEW:❑ RENOVATION:';/ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER I DRINKING FOUNTAIN • FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ' � Sl�� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES fi NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY 0 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El I hereby certify that all of the details and information I have submitted or entered regarding this application are true and'accurate to i-best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al ' ent• ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �• I PLUMBER'S NAME Spencer Hallett LICENSE# � -'� 16224 ,/ • .•�� MP[2' JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Spencer Hallett Plumbing and Heating ADDRESS 381 Old Falmouth Rd Unit 36 CITY Marstons Mills STATE MA ZIP 02648 TEL 508-428-6080 FAX 508-428-7991 CELL EMAIL spencera©hallettplumbing.com (7 \ �V \\ I` I d� �� \\^ � Vl � r. I`J V �. Vi