HomeMy WebLinkAboutBLDP-18-06616 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`;.moo� _�41® CITY /crmocS�porf MA DATE S//5/%8 PERMIT#f//1-6Vd64.
JOBSITE ADDRESS 7/ U&tcl SAcrG Cc , OWNER'S NAME Suc.LnnG Mc nu I% _
POWNER ADDRESS TEL S09-3 4 3359 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I I EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:I I REPLACEMENT:ie PLANS SUBMITTED: YES I NO
FIXTURES-1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB U J I I I U I U II U 1 U I
CROSS CONNECTION DEVICE X I l I IL U U IL U 1 U
DEDICATED SPECIAL WASTE SYSTEM II J IL 1 I 1 IL U I I II U I U
DEDICATED GAS/OIL/SAND SYSTEM I U If I U U
DEDICATED GREASE SYSTEM I I d 1 U ILL i � H
DEDICATED GRAY WATER SYSTEM ( 11 E l 1 LI 1 U -U I I f
DEDICATED WATER RECYCLE SYSTEM U U I U U.11 U U I < U
DISHWASHER I H l II i U U 1 i I L. 1 U
DRINKING FOUNTAIN L U f U U U U I I. U .I U I I U
FOOD DISPOSER U r I
U 1 1 111.
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I I I 11 r _1L r 11 J
U I
KITCHEN SINK
LAVATORY I U p I U I
ROOF DRAIN I I I i ! .11 I I I H H
SHOWER STALL L__ U I II U 1 JI U I I U
SERVICE/MOP SINK II t L i, _ . 1
TOILET
1 I I ! U
URINAL
ll 1 I 1, 11 L ll � � I
WASHING MACHINE CONNECTION I I I L I U II U_ I
WATER HEATER ALL TYPES I jG _I L J I 1 �. I. I I. _ I
WATER PIPING I— I _ I d 1IL U I. it I
OTHER _ I ._ it II . L ._.. II _ 1
. L L I L. II U 1 _IL I I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES C NO U
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 7 OTHER TYPE OF INDEMNITY 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 I AGENT 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 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 it aft-Pertinent p vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME,James Pazakis LICENSE# 15030 SIGNA E
MP i JP__ CORPORATION U# C-3984 PARTNERSHIPU# LLC #
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