HomeMy WebLinkAboutBLDG-19-006597 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY L 1 MA DATE Sl fil"--1 PERMIT#A,6991?` 6 7 /
JOBSITE ADDRESS 44 I gocIC(�r5laniff:2_ *3 I OWNER'S NAME „o f c -
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POWNER ADDRESS — TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I 1 EDUCATIONAL __i RESIDENTIAL,)
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CLEARLY NEW: Li RENOVATION:1-1 REPLACEMENT:p PLANS SUBMITTED: YES_ NOn
FIXTURES 1 FLOOR-. BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I,. , II -II 11 11 I1 l r-
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CROSS CONNECTION DEVICE I '' T I H IT -I II I i`
DEDICATED SPECIAL WASTE SYSTEM r— I I 1r_- 1s -i. �(---17
DEDICATED GAS/OIUSAND SYSTEM 1F-1 1 11 1 I(-
DEDICATED GREASE SYSTEM _- Y I... 'lu __ I I ( II 1
DEDICATED GRAY WATER SYSTEM -1 I li II II 1r . --I- li II
DEDICATED WATER RECYCLE SYSTEM r--II I I II II I 11 II I l'
DISHWASHER 1 ` .1 it ;-.:_-_.-11 _,r_ ,i
DRINKING FOUNTAIN I II -- 11 _ 11- 11 (1 ___.._..11 L.--fir 11 ._ 11- 1,_ .....__...1
FOOD DISPOSER . II :-_.._..—.li —11 II 1- 1r -1I --11 -- ..II_.
FLOOR/AREA DRAIN I -- , II 1 --11- II i�- �I-...---1
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INTERCEPTOR(INTERIOR) I —II-----_.11___-_11 —1I— 1 II II (I 1 I 11- iI-------1
KITCHEN SINK n --;I -11 --11 I(— d --I II ;1 ;1-- II 1I^
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LAVATORY F__..-----11-
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ROOF DRAIN 1I I1---i1 1r1I _ It II 1r__
SHOWER STALL 1--.1I- 1I------1I— I ii {{- II -_ 11 IF 11-
SERVICE I MOP SINK P 1 -11 I 11 II - 1 11 11 I I Ir II IH i
TOILET ?! I I I I I I 11 II II 1r`-- 7-1
URINAL I 11 ---11--_-1 r- L..__._.._11 II I- 1 1 r I I I I—_-1 ---1
WASHING MACHINE CONNECTION IIIII i(— i II I I I{- 1 11 17 11
WATER HEATER ALL TYPES I I_ -,I 1 ( it IF I — I--- I____ _
WATER PIPING ,� 11 I
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OTHER II II Ii I H 11 r.___ I Ir---
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES I i I NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Fl OTHER TYPE OF INDEMNITY u BOND I I
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 1 I AGENT [1]
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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli ith inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME James Pazakis LICENSE# 15030 SIGNATURE
MP 71 JP! ] CORPORATION , # C-3984 PARTNERSHIP(l# LLC #
COMPANY NAME i JM Pazakis Inc. ADDRESS 447 Old Chatham Road
CITY[South Dennis 1 STATE P MA1 ZIP 02660 TEL 508-385-9127
FAX 1 CELL 1 EMAIL
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