HomeMy WebLinkAboutBLDP-19-003757 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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7o � CITY WEST YARMOUTH MA DATE 12/20/18 PERMIT# tYl /7'6'C'3 j5l
JOBSITE ADDRESS 196 HIGGINS CROWELL RD I OWNER'S NAME JEFFERSON DEXTER,DMD
POWNER ADDRESS SAME j TELr508-398-3322 FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL i EDUCATIONAL -_j RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: i REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER .
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL _
SERVICE/MOP SINK 1
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1
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
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i 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 R'
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 the b-- 'of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe , rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��L
PLUMBER'S NAME R Peter Checkoway LICENSE# 13417
SIGP,' URE
MP / JP CORPORATION # PARTNERSHIP # LLC, 1-
COMPANY NAME Checkoway Enterprises ADDRESS 111 Scargo Hill Rd
CITY Dennis STATE MA j ZIP 02638 TEL 508-385-1911
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FAX 508-385-6858 CELL 508-735-9993 EMAIL checkent@comcast.net
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