HomeMy WebLinkAboutBLDP-17-004573 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_:.ip=I:`
S_'-tig CITY I ar NICE )'�.1 (A)1--4 MA DATE `j'a l /'I PERMIT# �/'-/7-ai 1 j
JOBSITE ADDRESS E 2- 1-4 Rats 1(l4 k OWNER'S NAME �.ek.A{,YS
POWNER ADDRESS ± TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT _
CLEARLY NEW:Q RENOVATION:- REPLACEMENT PLANS SUBMITTED: YES❑ NOl,
FIXTURES 2 FLOOR BSM 1 2 3 4 1 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 all MI _ _
DRINKING FOUNTAIN ®®
FOOD DISPOSER
FLOOR/AREA DRAIN -
INTERCEPTOR(INTERIOR) __ _ _ _ _
KITCHEN SINK ��
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK
TOILET 11111M5111111=111.1111111
URINAL IS
WATER HEATER ALL TYPES
WASHING MACHINE CONNECTION MINEEM.0=====
WATER PIPING
INNIMEMPIIIIMMIMMINIMMEIMIIIIIMMUMIllOTHER
I
;,1- - ,E=9.E. '1--- a-- II .0 '
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY iL. OTHER TYPE OF INDEMNITY❑ BOND 77
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 ENT Li
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 acc to t b y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc I P ne r sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME RICHARD OLSEN LICENSE# M10335 SIG URE
MP E JP❑ CORPORATION❑# 2166 PARTNERSHIP❑#( I LLC❑#1
COMPANY NAME OLSEN PLUMBING&HEATING ADDRESS 357 HOKUM ROCK ROAD
CITY DENNIS STATE 7 MA I ZIP 02638 TEL 1508-385-5290 1
FAX 508-385-6963 CELL EMAIL OW%(.-Q 0 e) .? ))1 ty-,to ,1 WIECEIVED
t I MAR 9,517� LR_
1 irr�IEPAR?MEN"f
� �
� �
0
� o
�.