HomeMy WebLinkAboutBLDP-20-001953 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Its CITY yor _____ _ ---- _ I MA DATE(-/O7J1 t'(........_] PERMIT#/ PP 6-4/?66
JOBSITE ADDRESS Scc __Seat te, Dr-5,,v- 1 OWNER'S NAME M'��o _ �//
OWNER ADDRESS [ J TELL FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL -1 RESIDENTIALM
PRINT __
CLEARLY NEW: , I RENOVATION:N REPLACEMENT: PLANS SUBMITTED: YES(_ l NO_ _
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ... !f li a ( _ IF IF
CROSS CONNECTION DEVICE l _
DEDICATED SPECIAL WASTE SYSTEM
— Ir
DEDICATED GAS/OIL/SAND SYSTEM i
DEDICATED GREASE SYSTEM 1 i.: i
DEDICATED GRAY WATER SYSTEM II 1, I 1
DEDICATED WATER RECYCLE SYSTEM __. ...1r- . ' 11 _ I __._. 1 1' -1
DISHWASHER j' _ I - 11- _1r
DRINKING FOUNTAIN I __.._ -11.. 1! ..._._.1 -- -i(
FOOD DISPOSER I II 1: 11 [ 11
FLOOR/AREA DRAIN r ,1._ 0 Ir__ ir_.._-_.1 I
INTERCEPTOR(INTERIOR) r -fir -11..._ it If Ir li-__._ I __-I 11
KITCHEN SINK —' ----- -_ __-;
I� II IF
LAVATORY I „ a I i I
ROOF DRAIN __ __
I
SHOWER STALL -
SERVICE/MOP SINK II 1.
TOILET i s , ( --if, _ T
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URINAL i I_ __.fir` IL__ �,:
WASHING MACHINE CONNECTION x I I(— r
WATER HEATER ALL TYPES
WATER PIPING r i
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OTHER —11 ---11-._ -- --11
j I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES[J NO L
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L�J OTHER TYPE OF INDEMNITY L_ BOND j •1
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 L_I AGENT ..I
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 a to to it a- V my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli e w• all-Pertinent. .vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME James Pazakis - j LICENSE# j 15030 7 IGNATURE
MP i JP CORPORATION L'J#(C-3984 PARTNERSHIP _J LLC',J#
COMPANY NAME JM Pazakis Inc. ADDRESS 447 Old Chatham Road
CITY I South Dennis 1 STATE r MA ] ZIP 02660 I TEL 508-385-9127
FAX I CELL L- 1 EMAIL
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