HomeMy WebLinkAboutBLDP-18-000715 r - , T - R
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
b1 CITY S-1-41 /ter m0J�'� I MA DATE 8I0/17 PERMIT# LdP-Ar-coo7/5-
JOBSITEADDRESS I 1 7 (,,)iIc'n Esc Cy r OWNER'S NAME 1-JDi,---(T„- ,XQ��-Ft (,JcrSik//
POWNER ADDRESS TEL 5ct-358-8'-1�' _FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL :'
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:g PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1. FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 0 JJ 1 $J 1 E 0 111
CROSS CONNECTION DEVICE 1 0 U 0 t El I _ II It
1
DEDICATED SPECIAL WASTE SYSTEM j 0 El E 0 El ii 1111111
DEDICATED GAS/OIL/SAND SYSTEM j 11
DEDICATED GREASE SYSTEM I ( 1 t I. I i''
# I ll I i
DEDICATED GRAY WATER SYSTEM 1 L I
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DEDICATED WATER RECYCLE SYSTEM I Mt
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DISHWASHER 1 , +' I I I 'I 0 # , 0 i
DRINKING FOUNTAIN 1 Ii ll Ii U IL, 11 Ii 0 El F 11 0
FOOD DISPOSER I El I. U F F
FLOOR/AREA DRAIN I I 1. U � 1, El I 1 1. 1 6
INTERCEPTOR(INTERIOR) I El 1 1 0 Ii Ii I. 11 0
KITCHEN SINK II 0 I I (J JJ ' __ _. LI
LAVATORY J X L- I t I 0 I ... .` ti - l_;,. 1 . J
ROOF DRAIN I 0 U 0 ► i 111
SHOWER STALL K11_ I J I J el I _ i
SERVICE/MOP SINK I_ U_ I I I r 1
II, i
TOILET J .X II 1 i J J , wiit 'i�,j
URINAL J 0 ,J t 0
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WASHING MACHINE CONNECTION �J F �pJ J J . i .
WATER HEATER ALL TYPES � 0 U U J Ii t 0
WATER PIPING J I I 0 I. El . 0 0 l 0 JJ I U
OTHER .1 i i l 1 IC 0 1 i
11 11 11 I I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 ❑ 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 accura - . :best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp all Pertin: t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME James Pazakis LICENSE# 15030 j SIGNATURE
MP❑ JP❑ CORPORATION❑# C-3982 PARTNERSHIP❑# LLC❑#
COMPANY NAME Hall Plumbing&Heating Inc. I 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