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HomeMy WebLinkAboutBLDP-18-001427 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ` CITY I r a1 V1; � '! MA DATE 'it PERMIT# `��J�� /�` JOBSITE ADDRESS '.-� A E 5 I. w 1 OWNER'S NAME:-gfT '✓'F -,V N U 1 OWNER ADDRESS i Ci' ; TELJ!/d 7 .S 37 7 FAX' ..,,_,..Yw.-. TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL `..-.; RF,SIDEN1IAL-a�,,,' PRINT I �J'L`a© CLEARLY I NEW:7 RENOVATION: ,„ REPLACEMENT: Cl� cJ S SUBMITTED: YES NO`+g ,. i .� Pi 201 1 FIXTURES 1 FLOOR-4 SSM 1 2 I-�-3 I i� 5 1 6 7 ;.._ 8_ i 10 ' 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ; DEDICATED SPECIAL WASTE SYSTEM ;,. 'r ^ , DEDICATED1- lila , DEDICATED GRAY WATER SYSTEM ,._ .FLOOR/DEDICATED WATER RECYCLE SYSTEM 1- 11',, , +INTERCEPTOR - ' '_"JJ_ .1.._=='m"31 INTERIOR , j KITCHEN SINK $111110111110M1.1111110011111010011.1111111~11.11.001.111.0i LAVATORY ROOF DRAIN SHOWER11111 1 TOILET _ '.,. mi sim WASHING MACHINE CONNECTION WATER HEATER ALL TYPES , WATER PIPING �. _ - 4, ro OTHER j g INSURANCE COVERAGE: I have a current liabiilly Insurance policy Or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING:THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY f� OTHER TYPE OF INDEMNITY i BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not tiavi 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 U SIGNATURE OF OWNER OR AGENT -� I hereby certify that all of the details and information I have submitted or entered regarding this applicatio re true a accu to th eat my knowledge and that all plumbing work and installations performed under the permit Issued for this application will in comp' ce with Pert! ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME;ANDREW LEIGHTON 'LICENSE#j 16130-M - NATURE MP JP j CORPORATION # 3734 -PARTNERSHIP,p„�,,-#j LLC COMPANY NAME; HALL OIL COMPANY INC. i ADDRESS 435 RI 134 - CITY irSOUTH DENNIS � :STATE - MA s ZIP 102880 _ t TEL 1508-398-3831 ___.. ,._.,,__._, FAX 508-394-3068 1 CELL' 1 EMAIL 21alloilcom an kmaii,�m ""-