HomeMy WebLinkAboutBLDP&G-18-000731 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-- it 4 CITY 0 CO2 n"-61n-'-"'1� MA DATE . .. .. •<. . . PERMIT#/9� f /0 73
JOBSITE ADDRESS .t' t -Ct_ .. 1. '
a�!>rJu t''�`..�. l(5� . ; OWNER'S NAME �V� '
P OWNER ADDRESS TEL l .S.S 1. FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL , EDUCATIONAL '•, RESIDENTIAL: '
PRINT
CLEARLY NEW: • RENOVATION: : REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 . 7 B 9 10 11 12 13 . 14
BATHTUB _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM - , ... .. .. . _
DEDICATED GAS/OIUSAND SYSTEM ..,... _� - ,. .. ._... .,. . ..�,. .,...
DEDICATED GREASE SYSTEM r; .. . ..
DEDICATED GRAY WATER SYSTEM .... .., .. .
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
. .. . . ... ....... .. _. .... ,. ,_.., .. ... ,...., .,...., . _.
DRINKING FOUNTAIN
- .... .._.
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _ ....,. ..
KITCHEN SINK
LAVATORY . .__ . .,, . . r ... ,.. __,.. , ..,.4., ,..,...., ,...... ..._._. ........_. . .L. »t... . ., . _...
ROOF DRAIN . .
SHQWER.STALL .. .. .. .... . -......._ .. ...... ...... ....._.,� ,.. _... ..,. . .......i_..�._._ ..,r.� -... __.,�,,. . . ..
,SERVICE/MOP SINK . »..- ........-._..... . ,_ _. _....- _.., . �,. . r...
TOILET-
URINAL ».. ....,, �.. ... ... - u .
WASHING MACHINE CONNECTION t .., �,, ._.. .r.. . - r. .»..... c.. ... . ._'. _...
WATER HEATER ALL TYPES -. .. .. . .. , . . z. . ._ i
WATER PIPING . . . ..-.. ... ..._.._. ....._ . _. ., _ _ _ ....
r
OTHER • �.
. _ ... . , ..,. . ., .. .... .. ......... ... . .. .,
INSURANCE CO ERAOE: -
I have a current Ilabillty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES .y. NO -
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 I .
SIGNATURE 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 tFi t of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be In corn ttf Ali P nt provi n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws,
PLUMBER'S NAME TIM MCELROY j LICENSE# 15'993 URE
MP JP CORPORATION # PARTNERSHIP #. LLC #
COMPANY NAME CAPE COD MASTER PLUMBERS, INC, l ADDRESS.70 CRANBERRY HWY P•0,BOX 75'6 1
I STATE MA J ZIP 02561 _
CITYSAGAMORE .. ... .. .. .... ... ._._ . ,
TEL�50
FAX CELL
&317-8525
EMAIL ,.,__. . .. . . ... . .. .. . ........ .. .
/ ./, /--1-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
4 1;1- yi CITY vv' U IA- � MA DATE PERMIT# / / / D"4'7'3/
JOBSITE ADDRESS t 't C S'+ 0,T OWNERS NAME L ' '- 'L S
GOWNER ADDRESS TEL C -}. S c S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL X'
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: x' PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS—) ESM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE _
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES I ° NO
I IF YOU CHECKED YES,PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ' OTHER TYPE INDEMNITY BOND I
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 ail of the details and information I have submitted or entered regarding this application are true and accurate to the best of my kn edge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinemtprovisi the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME TIM MCELROY ' LICENSE# 15993 .� E
MP MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME CAPE COD MASTER PLUMBERS,INC I ADDRESS 70 CRANBERRY HWY P.O,BOX 756
CITY SAGAMORE I STATE MA ZIP 02581 ITEL 508-317-5525 j
FAX CELL EMAIL