HomeMy WebLinkAboutBLDP-19-005925 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY 1 A w`0 J � PIAPIAMA DATE PERMIT#,ar,Op"�—5-9.2c
JOBSITE ADDRESS 11 F-x' OWNER'S NAME -JO � LG,tip-,
OWNER ADDRESS �oc<.n ln�� flu TEL ) � Z b'i `t3FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El
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CLEARLY NEW:El RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El
FIXTURES T FLOOR--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND 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
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 RI/NO ❑ ,
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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LIABILITY INSURANCE POLICY N1 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 El
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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al e ent ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Spencer Hallett LICENSE#16224
MP[2' JP❑ CORPORATION❑# PARTNERSHIP❑# LLC El#
COMPANY NAME Spenser Hallett Plumbing and Heating ADDRESS 381 Old Falmouth Rd Unit 36
CITY Marstons Mills STATE MA ZIP n2648 TEL 508-428-6080
FAX 508-428-7991 CELL EMAIL Spencer jhallettplumbing.com
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