HomeMy WebLinkAboutBLDP-19-006276 1,,,,,,,,,,,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I` CITY[j c >6 r y'Y>W', 1 MA DATE ..._S13//c( PERMIT#/ �19'Ce ' -4°
JOBSITE ADDRESS 117 LAW?n �Q OWNER'S NAME o �
/Q 1
PJ . . .e�s
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL I I RESIDENTIAL 0 74'
PRINT
CLEARLY NEW:I I RENOVATION:I I REPLACEMENT: PLANS SUBMITTED: YES I I NOn
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB II I I I 1 I _ I II I II I I
CROSS CONNECTION DEVICE 7----Tr- I I I II I -- I I
DEDICATED SPECIAL WASTE SYSTEM 1 IF, 11 IF ( 1 I _II IIr I __ 1r 1! 11- 1r---1i 1
DEDICATED GAS/OIUSAND SYSTEM - [__ '
-1 II . _ IF Ir 11 1r 1C P 1r 11 1 1
DEDICATED GREASE SYSTEM 1 I }r ( r I !I
DEDICATED GRAY WATER SYSTEM r _ 11 11- Ir 1 i. II 1I_ f 11 lF 11----1 1
I IF II II — -11- I 1 _Ir- 1! _._ l
DEDICATED WATER RECYCLE SYSTEM I I I 11 �_- I l
DISHWASHER l f _ _ II __ 11 -_ I II_ I1-11 it F it !
DRINKING FOUNTAIN I PP II r �11 11 —IF 11 IF r— ii 11 II 11 it 1
FOOD DISPOSER I 1--1 11 11 II 11 II it r -1 -1. —11 IF it l
FLOOR/AREA DRAIN I il I 1 II I II tI I II f 1I 1
INTERCEPTOR(INTERIOR) I IF II IJ II I 1 tF II 11 II 11-1I 11_1__ 1
r- F; II II ;l al II II ! I I II ,I - !
KITCHEN SINK _ 74 _ I —1
LAVATORY _ I Ih it �1 11 11 II 1i 1r I I —
11 1, l __
ROOF DRAIN 6 li -1 I II 11 II '1 1!
SHOWER STALL I II II 1 II II II II II II II 11 Ir lr_ _
SERVICE I MOP SINK I !I 11 II II II 11 IF 11--11 II II 11 ii —II 1
TOILET : _. —lI II II II___II I II ,III II ,i If I
— URINAL I II II II ll II 1 Ii II II II II II ii II I
WASHING MACHINE CONNECTION I II II II II II `I II II —11 II 17 If 11— 11 1
WATER HEATER ALL TYPES -'II II I 'I I II . 1 II i 'I II 0
WATER PIPING 1 II II II II II 'I II 11 II 11 II II II II 1
OTHER III If 1I II II 1 II II II 11 II II _11 II
,1 IF II 1I II I II 'I II
11111
I II II IF II 1—Ir— 1
1� I 1, IT-11 11 II If II 111 If 1
1 INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES j v I NO 1 I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY!�J OTHER TYPE OF INDEMNITY LI BOND 1 1
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 f 1 AGENT n
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 I James Pazakis LICENSE#115030 1 SIGNATURE
MPH JPD CORPORATIONL,J# C-3984 PARTNERSHIP Li#I ILLCI I#
COMPANY NAME JM Pazakis Inc. ADDRESS 447 Old Chatham Road
CITY South Dennis STATE MA I ZIP 02660 TEL 508-385-9127
FAX r 'CELL EMAIL L
4_1?`!
UGH PLUMBING IN PECTION NOTES RELOVI FOR OFFICE USE ONI,I FINAL INSPECTION NOTES
•./. /2/9 01/7
P(14-In 0 Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES