HomeMy WebLinkAboutBLDP-19-005163 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY So&i4 �n rvr1p6.14_ MA DATER PERMIT#I/)P-1/'DU5161
JOBSITE ADDRESS /)7 (..A-) l:c;'►‘ OWNER'S NAME 400L -r-dZ C,ce'isiP�¢�
P OWNER ADDRESS TEL FAX, �J
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL&)
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CLEARLY NEW:Li RENOVATION:❑ REPLACEMENT:: PLANS SUBMITTED: YES LI NOfl
FIXTURES 1 FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r -11 - Ir II iI ( I _ 11 17-1
CROSS CONNECTION DEVICE lI d ' II I� II i[ i —li 11 i
DEDICATED SPECIAL WASTE SYSTEM y II II !!' IT-- 11 1 r-1IT I i1 .- I
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM r 11 ii _ _ 1 If `I {I__ ll I II Il p
DEDICATED GRAY WATER SYSTEM I If - li (r , . . 11 1„ , 1 I.
DEDICATED WATER RECYCLE SYSTEM II r 1 I 1�-_ ��-, II_ _.{I_ 1 . I Ili
DISHWASHER 1 li - _ 1 I_ I�_ r �i �i III r I_ _ I
DRINKING FOUNTAIN 1- 11 II —1 11- 1r 11 r 1 .if I
FOOD DISPOSER J I,1 --1 .�11 1 I {' 1 . I ._ Ir 'r_ I
FLOOR/AREA DRAIN I— -1,[-1,[ - (� — II -11--r_-I 1 Ir
INTERCEPTOR(INTERIOR) [---1 11 I 1 r-1 I1---1 Ir 1
KITCHEN SINK I-- I I lI I 1r II I �! fl I I 1
LAVATORY r -ti>{1. .. I _.. II II I II II lr _ 1
ROOF DRAIN I II I I II I I I I In i(— {
SHOWER STALL I 11 > I 11 11 I II 1 I II 11 11 1 {
SERVICE I MOP SINK { 1 I 1--1I II II ,1 II , I� 11 II 1 11 1I -1
TOILET 1—1I .II II 'I 'I II 1 II 1 I !1 1- I
URINAL I II I 1 11 II II II 1 1 1 1
WASHING MACHINE CONNECTION I 1 II IF II 111 II 11 (I I I II 1[ I
WATER HEATER ALL TYPES II II II .1 II 1r 11 1 it 1 1 (- I
WATER PIPING ___—I 1 I 1_. 1 ,.---11 I 11 11 1r1 II 1r Ii--__--
OTHER 11I 1 II I` _ I1 I1 I II II I -1r II I
;I I I I a I
_1I1 I IF 11 -li I I I I 1 _ I
-1 I 11 1- II I I _ fI-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I I 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 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 and accurate to the bes f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia 'th all Pertine rovision of the
• Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME James Pazakis LICENSE# 15030 SIGNATURE
MPI I JP El CORPORATION # C-3984 PARTNERSHIPr 1# 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