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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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7 1 . S CITY Y rryie,i poi MA DATE Ia/I i //8 I PERMIT#/3`+/V-1T:-.19° 76r-
JOBSITE ADDRESS L8S C.vr a,,,,p eoacQ OWNER'S NAME
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OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I I EDUCATIONAL ❑ RESIDENTIALV
PRINT
CLEARLY NEW:❑ RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES_ NOI-J
FIXTURES 1 FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I _. I II II _ II I I I II II 11
CROSS CONNECTION DEVICE I II I! II I IL I II IL 4
DEDICATED SPECIAL WASTE SYSTEM r II 11 II ,, II .____ II I 1 1 !f I
DEDICATED GAS/OIUSAND SYSTEM --I If I!�-iI I I II II II 1 I _�1 I 1
DEDICATED GREASE SYSTEM I _ -! I I J —I I1__ .. I[- 1': -I
DEDICATED GRAY WATER SYSTEM _Ir-1 I _ 1-
i I __..._1
DEDICATED WATER RECYCLE SYSTEM -I I II _ Y -IJ (_- -1- 1 .
DISHWASHER I-1—IF II II I II I IF 1 _i II I1 II I
DRINKING FOUNTAIN J IF II J . .. . I . 1 .. I -i--I I
FOOD DISPOSER I II I If II 11 I I I I
FLOOR/AREA DRAIN MI If I I II II I II II I II II II 1
INTERCEPTOR(INTERIOR) 1 I I 1 I I I
KITCHEN SINK I II _ IIJr---- '1 I II I .. _ II II_ II II ..II II II
LAVATORY Iyo_II_ II . _ I II I 1. I.. .__ _I I IL1
ROOF DRAIN I II II II f II iJ I II II 1 II II I
SHOWER STALL I II II --71 II I I I II II I I I
SERVICE/MOP SINK I--- , I II I II II I II I I I I I I
TOILET I -1I I I1 II II I II I iI 11
URINAL --1I 11 I I I I
WASHING MACHINE CONNECTION 1 I II I I I I
WATER HEATER ALL TYPES II lI II ; -1 1I II II I II 1 6 1
WATER PIPING -__lr_- II 1r ,I -II II II 11 I I II II I
OTHER I 11 I II— -I I I II II I I
I 'I I I II II II II II_ I
___ 1 . II. -II I I -11 II I 11 I I, ' II I
1 II I -I -TI I II
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
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY U 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 I 1 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 and accurate to the f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli I all Pertinent pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME James Pazakis LICENSE# 15030 S N
MP , JP CORPORATION❑# C-3984 PARTNERSHIP❑# LLCI #
COMPANY NAME JM Pazakis Inc. ADDRESS 447 Old Chatham Road
CITY' South Dennis STATE MA ZIP 02660 1 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