HomeMy WebLinkAboutBLDP-18-003080 tA
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
lifS CITY I 104,11fY1d V ?ot('4 ' MA DATE: \I `LL I, 7 PERMIT#,,U/-/I-COGIO
JOBSITEADDRESS '1 q ale 6 A OWNER TEl n i
OWNER ADDRESS j . TEL -gJ )v, F , 9
P � f
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL IL
PRINT
CLEARLY NEW:K RENOVATION:E REPLACEMENT: PLANS R ED: YES 0 NO N-
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE ____ _ _, _
DEDICATED SPECIAL WASTE SYSTEM __
DEDICATED GAS/OIUSAND SYSTEM _ _
—_ _ _ �_
DEDICATED GREASE SYSTEM _ �.-.
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM . . Mil _
DISHWASHER
DRINKING FOUNTAIN . __
FOOD DISPOSER
FLOOR/AREA DRAIN _ ,
INTERCEPTOR(INTERIOR) T
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL MI IM .__._,=MI
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPESdi WATER PIPING L__ lif T — _— aJ --
OTHER _ _. _. --- _ _
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[J OTHER TYPE OF INDEMNITY Imo' 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: OW ER ! AGENT L
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 d r t est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in' ian it n t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME!RICHARD OLSEN !LICENSE#j M10335 I SIGNATURE
MP. JP CORPORATION# 2166 PARTNERSHIP❑#' LLC_#
COMPANY NAME OLSEN PLUMBING&HEATING !ADDRESS 357 HOKUM ROCK ROAD
1
CITY DENNIS STATE 1 MA j ZIP 102638 f TEL 1508-385-5290
FAX 508-385-6963 CELL I EMAIL
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