HomeMy WebLinkAboutBLDP-22-004422 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
p, A- '• CITY IYARMOUTH I MA DATE 12/8/22
1IPERMIT# BLDP-22-004422
JOBSITE ADDRESS 1303 ADMIRALTY HEIGHTS VILLAGE OWNER'S NAME'FRANKLIN MICHAEL C
P OWNER ADDRESS IFRANKLIN JILL H 1 LEXINGTON CIR CANTON,MA 02021
I TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑
PRINT RESIDENTIAL ❑
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑
FIXTURES • FLOORS-- BSM 1 2 3 4 5 6 7 8 9
BATHTUB10 11 12 13 14
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
YES❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate 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 with all Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME IJohn Hesketh I LICENSEIMA I
SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑#
LLC ❑#
COMPANY NAME ICapeway Plumbing&Heating I ADDRESS 75 Janebar Circle
CITY IPLYMOUTH I STATE MA
ZIP 02360 TEL
FAX CELL 5088883882
EMAIL
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