HomeMy WebLinkAboutBLDP-20-003427 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ukf CITY WEST YARMOUTH MA DATE 12/13/19 PERMIT# /A91 4 cv 3'//7
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JOBSITE ADDRESS 875 GREAT ISLAND RD,W Y OWNER'S NAME PAUL CUSHMAN
POWNER ADDRESS 1170 5TH AV, NY,NY 10029 TEL 508-790-7863 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: RENOVATION: 'I REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES 7 FLOOR 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 1 -
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 2
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION 1
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 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.
CHECK ONE ONLY: OWNER AGENT I
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 s f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with alllPP'eer, ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. s �
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417 SIGN�I.T E
MP ' JP CORPORATION # PARTNERSHIP_j# : LLC #[
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COMPANY NAME Checkoway Enterprises ADDRESS 11 Scargo Hill Rd 1
CITY Dennis STATE MA ZIP 02638 TEL 508-385-1911
FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net