HomeMy WebLinkAboutBLDP-20-000671 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r"1'( CITY WEST YARMOUTH MA DATE 5/2/19 1 PERMIT# /*-e `49 07f
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JOBSITE ADDRESS 66 LAKE RD,W Y OWNER'S NAME ANN PETERSON
OWNER ADDRESS L192 WILSON ST, MARLBORO 01752 TEL[508-561-2097 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL lel RESIDENTIAL
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CLEARLY NEW: RENOVATION: REPLACEMENT: __a PLANS SUBMITTED: YES NO_
FIXTURES Z FLOOR—o 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/OIL'SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK j
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I NO L.
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSLRANCE 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.
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 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 a ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R Peter Checkoway (LICENSE# 13417 SIGNATURE
MP JP❑ CORPORATION #r PARTNERSHIPQ#[ LLC #
COMPANY NAME Checkoway Enterprises j ADDRESS 11 Scargo Hill Rd
CITY Dennis STATE MA 1 ZIP [02638 + TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net