HomeMy WebLinkAboutBLDP-17-002860 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
fir\ CITY/TOWN ' �2� MA DATE 1 I` S-ko PERMIT#��P-J7`�t; 0�(�
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JOBSITE ADDRESS 0 � �2
al-- ,nal.c� `mac OWNER'S NAME • Kis Fa.rtgAQ__
POWNER ADDRESS 1 3�- / ( TEL OZ-Z ) ( FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL g•-•"-----
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z 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
DRINKING FOUNTAIN 1 •
FOOD DISPOSER \
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I
WATER PIPING
OTHER Q '1aA)
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 ❑
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 bes f my kn edge
and that all plumbing work and installations performed under the permit issued for this application writ be in comer tpkTce vfth all Pertine isi f e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Dmitri Chalke LICENSE# 10322 SIGNAT
MP® JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
PO Box 304(1378 Main St), East Dennis 02641
COMPANY NAME D.Chalke ADDRESS FOR SEASIDE GAS:67 Helmsman Dr
CITY Yarmouth Port STATE MA ZIP 02675 TEL 508 294 8361 Dmitri cell
Seaside Gas/Kevin Saunders Dmitri@seasidegasservice.com
FAX CELL 508 400 0943 cell EMAIL
�1 -5 G,R
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THS APPLICATION SERVES AS TIE FERMI ❑ ❑
FEE $ PERMT#
PLAN REVIEW NOTES