HomeMy WebLinkAboutBLDP-16-004203 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
a"�0 CITY p 1 MA DATE 1 I ci i Lc PERMIT#, /& -C-Q q
JOBSITE ADDRESS I Lit. I>�k f� -i _1 I I OWNER'S NAME , bd�.r f`Jy
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POWNER ADDRESS I _ _ TEL FAX E
TYPE OR OCCUPANCY TYPE COMMERCIAL 71 EDUCATIONAL D RESIDENTIAL
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CLEARLY NEW:1_„ RENOVATION:Ei REPLACEMENT: PLANS SUBMITTED: YES 1171 NO:
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ' ' I:. Mill
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM " ;i
DEDICATED GASIOIUSAND SYSTEM AL :_ 1 ``' g�
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM ' _ M
DISHWASHER {
DRINKING FOUNTAIN $' a � ".��.��;
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) ;, 3
KITCHEN SINK - . ,_
LAVATORY ti " ' _
ROOF DRAIN _ M FT_ _ �..- 111111,111.111 W
SHOWER STALL i ' •
SERVICE f MOP SINK F ' . '
TOILET .�_.
URINAL
WASHING MACHINE CONNECTION a
-71I 3.
WATER HEATER ALL TYPES
WATER PIPING . r
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OTHER
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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 IFE NO El
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 aup accurate he best nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co a wit ertine of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ._--�
J�PLUMBER'S NAME RICHARD OLSEN LICENSE# M10335 SIGN lie
MP 1, . JP CORPORATION 2166 PARTNERSHIP#�— LLC[�#
COMPANY NAME OLSEN PLUMBING&HEATING ADDRESS 1 357 HOKUM ROCK ROAD
CITY!DENNIS STATE MA ZIP 02638 TEL 508-385.5290
FAX 1508-385-6963 1 CELL EMAIL