HomeMy WebLinkAboutBLDP-19-004996 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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s. \ s5 CITY YARMOUTHPORT Y MA DATE =2-12-19 PERMIT#/ PiD7�l 77G�
JOBSITE ADDRESS 24 BRATTLE DR,YPT OWNER'S NAME LORI GULLIVER
POWNER ADDRESS SAME _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO0
FIXTURES-1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
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CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM i _
DEDICATED GAS/OIL/SAND SYSTEM
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DEDICATED GREASE SYSTEM 1a ,il,_
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DEDICATED GRAY WATER SYSTEM 1 ,, , 'v. _ . I _ I
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER 1
FOOD DISPOSER DRINKING
FOUNTAIN _
FLOOR/AREA DRAIN 111 '
INTERCEPTOR(INTERIOR) I
KITCHEN SINK
LAVATORY
ROOF DRAIN 1
SHOWER STALL
SERVICE/MOP SINK
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TOILET
URINAL
WASHING MACHINE CONNECTION '
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WATER HEATER ALL TYPES
WATER PIPING II1111111111111111
OTHER i
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BAR SINK _ _...._ _ m_,
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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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY Q BOND Li
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 Li 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 are true and accurate to the of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P rti rovisi he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway ,LICENSE# 13417 URE
MPE JPO CORPORATION®#w PARTNERSHIP 0# LLCO#
COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Rd
CITY Dennis _ _ STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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