HomeMy WebLinkAboutBLDP-18-006614 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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I CITY .jp -rylp� 1 MA DATE sli5//8j PERMIT# � �i7.'6 o�-t
JOBSITE ADDRESS 7a ( n`I')ck2(- -Le OWNER'S NAME S Diann
POWNER ADDRESS TEL &3 4.5D—395 3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL P1 EDUCATIONAL Li RESIDENTIAL 217
PRINT
CLEARLY NEW: RENOVATION:LI REPLACEMENT: 110.' PLANS SUBMITTED: YES LI NOU
FIXTURES Z FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ( JJ J M 1 11
J CROSS CONNECTION DEVICE J)G 1 I U J 8 I E
DEDICATED SPECIAL WASTE SYSTEM 1 11 IL 11 1 I. II II U
DEDICATED GAS/OIL/SAND SYSTEMLDEDICATED GREASE SYSTEM I 1 II i U i I I I
DEDICATED GRAY WATER SYSTEM I 0 I { L 11 II Ir I'll
DEDICATED WATER RECYCLE SYSTEM I I I II I I. I_ C DISHWASHER I t i 1L
DRINKING FOUNTAIN I I I U IL LI L i 1 ! U I L
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INTERCEPTOR(INTERIOR) L (I I If ] [(
KITCHEN SINK I U1 1 II I I. I !
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ROOF DRAIN l0 1 L t I Ill I,
SHOWER STALL I 1 L I I L L 1 ii 1. 1 L
SERVICE/MOP SINK J
TOILET II ( I I I i I I
URINAL l iI L. I I I I U ii I U J I
WASHING MACHINE CONNECTION I I.
WATER HEATER ALL TYPES
WATER PIPING r J L j I I I 1 i„, a
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1 J I 1 J L_11 11 11 II 11 I .
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 I I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY U OTHER TYPE OF INDEMNITY E BOND n
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 Li 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 an. . I ..- -- _- of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comps. - I Pertinent pro ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME James Pazakis LICENSE# 15030 Alp' SI ATUR ,_----"'"--
MP i JP_ CORPORATION ID# C-3984 PARTNERSHIP # LLCI I#
COMPANY NAME JM Pazakis Inc. ADDRESS 447 Old Chatham Road
CITY South Dennis STATE MA ZIP 02660 TEL 508-385-9127
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
1
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