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HomeMy WebLinkAboutBLDP-17-005386 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w MA DATE 1 l PERMIT#.40 _ "' CITY/TOWN 5 J41��1�C3�1�-�- •_ JOBSITE ADDRESS art 3O C`�4(6 sh OWNER'S NAME U-V.Ce\ OWNER ADDRESS 577 47. 7- TEL(17-63ci•( 3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: 0 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 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 cl WATER PIPING OTHER P� 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 0 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 ledge and that all plumbing work and installations performed under the permit issued for this application wiitbe in co nce vfith all Pertine isio f e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \` Cha lke Dmitri PLUMBER'S NAME LICENSE# 10322 SIGNAT MP® JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# D.Chalke PO Box 304(1378 Main St), East Dennis 02641 COMPANY NAME ADDRESS FOR SEASIDE GAS:67 Helmsman Dr CITY Yarmouth Port STATE MA ZIp 02675 TEL 508 294 8361 Dmitri cell FAX CELL Seaside Gas/Kevin Saunders Dmitri@seasidegasservice.com 508 400 0943 cell EMAIL CID 47,51i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El FEE: $ PERMIT# PLAN REVIEW NOTES