HomeMy WebLinkAboutBLDP-16-005598 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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_'�1 CITY 1 cif fi1O LYt h VJO{4 i MA DATE q 113( I(o PERMIT#6 -,W /b` '63 f
JOBSITE ADDRESS )L L 0 (o 1 OWNER'S NAME P. (JOS\ e... .MM I
POWNER ADDRESS TELj . . IFAX'_ _ w
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL A I
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT ',�... PLANS SUBMITTED: YES ri NOE
FIXTURES Z FLOOR-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB y m .. _ I ``
CROSS CONNECTION DEVICE ' 1, ''
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM "Y �� �.
DEDICATED GREASE SYSTEM = ,
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DEDICATED GRAY WATER SYSTEM , .,
DEDICATED WATER RECYCLE SYSTEM I t
DISHWASHER ;DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN �
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY '
ROOF DRAIN _ . _ .... �. . _._. _ ..., .
SHOWER STALL
SERVICE/MOP SINK Mai
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TOILET , ,rill 111110: :IN a' .' -. `,1 - :, -.. ., -7 nap,
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WASHING MACHINE CONNECTION
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WATER HEATER ALL TYPES MUM
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO ri
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY �` OTHER TYPE OF INDEMNITY BOND L,_
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
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 arcurate e best of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in I' wit i ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —
PLUMBER'S NAME RICHARD OLSEN LICENSE# M10335 y SIGNATURE
MP %, JP0 CORPORATION El 2166 PARTNERSHIP0# 'LLC[j#
COMPANY NAME OLSEN PLUMBING&HEATING ADDRESS 357 HOKUM ROCK ROAD
CITY DENNIS STATE MA ZIP 02638 TEL 508-385-5290
FAX 50&3B5 6963 CELL EMAIL
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