HomeMy WebLinkAboutBLDP-20-003455 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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5.TII E= CITY LS YARMOUTH ] MA DATE L2/10/19 1 PERMIT# /' 1---1.1I " O"C 4/Cr
JOBSITE ADDRESS L18 RITA AV, S Y OWNERS NAME CHRISTINE BALCH
POWNER ADDRESS �AME TELL508-294-2433 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ' REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES 7 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB —1—7- ---1---- —1' '` ,i---
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM 1
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
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DRINKING FOUNTAIN --"
FOOD DISPOSER -
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1
ROOF DRAIN Ii
SHOWER STALL -
SERVICE/MOP SINK — ___i
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES j_ . ,
WATER PIPING -11_
OTHER
11
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY v 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.
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 accurate to t st 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 I nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME[R Peter Checkoway • ___ LICENSE# 13417 i ATURE
MP .] JP0 CORPORATION®# PARTNERSHIP❑#� �LLC #
COMPANY NAME koway Enterprises I
Chec ADDRESS 11 Scargo Hill Rd j
CITY Dennis — STATE MA I ZIP 102638 TEL 508-385-1911
FAX 508-385-68581 CELL 508-735-9993 EMAIL checkent@comcast.net