HomeMy WebLinkAboutBLDP&G-19-002149 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• j `' CITY (�.(3�/Y�-Y\r�-01,E-i'1- MA DATE PERMIT#/31✓�iP"/r'addt(�/7
• - ' JOBSITE ADDRESSi — &LIB-S -
� N� : OWNER'S NAME Le�.:� .. _
OWNER ADDRESS . _ _. . . . TEL,Ccb`j -: .. ..
P 311-c5 5. FAX_..
TYPE OR OCCUPANCY TYPE COMMERCIAL . . EDUCATIONAL ,_ RESIDENTIAL.C
PRINT
CLEARLY NEW: . . RENOVATION: REPLACEMENT:K; PLANS SUBMITTED: YES •; NO
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is y.v�=V+-W.... - a aW A. x._ vvv, ,. , i.... 1 v .. .. _ ...,_.,.., .,v. ._`._ .. ., .. v..a,., ...V .>,....1....,.._. .- ' ,
BATHTUB
CROSS CONNECTION DEVICE - ._ , •
DEDICATED SPECIAL WASTE SYSTEM - ` , . .. , . . . .
DEDICATED GASIO1L/SAND SYSTEM , -
DEDICATED GREASE SYSTEM .. . .. .. _ .
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
Nuh.pm.o.ii�v. t f r
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) _,.. . .... .
KITCHEN SINK ;... . ... .. .. . . ... ... . . .
LAVATORY . .. . _ ... . .. .. .. _..... , ....... ,..... ...,.. .z.�.. ._ .., • .. .- .• .�.. ... . . .....
ROOF DRAIN _
ill 11^6.44 WIN-Li:•4T11iL .•
SERVICE I MOP SINK . .. ... °.: ..
..... ..._. ._..._ �., _,
•
TOILETr..... . .... 1....... a . . _T. ...... .. _.. ... . . ..
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING _ -
OTHER {{
. ..i. .. ..... .. , ..... ...... ,,. .. .. .. c. ,..
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INSURANCE COVERAGE:
I haves 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 d OTHER TYPE OF INDEMNITY BOND
j 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 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 a t of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In co nt provt n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 11M ML%t:LttU1' . LICENSE# 1WKI i'— — vATURE
MP JP CORPORATION ,# PARTNERSHIP ....
# LLC #
COMPANY NAME CAPE COD MASTER PLUMBERS,INC. t ADDRESS.70 CRANBERRY HWY P.O.BOX 758 ,
CITYSAGAMORE ISTATE MA I ZIP 02561 I TEL`508-317-4525 1
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r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_`=►I CITY oGL'z YVt. h MA DATE PERMIT#%/O/"l/04l yq
F i OWNER ADDRESS TEL 3 t 7 r FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL1j
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:j] PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 7. FLOORS BSM i 1 1 2 , 3 4 5 , 6 1 7 1 8 1 9 1 10 11 1 12 13 14
BOILER
CONVERSION BURNER i
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FACE
GRILLE ,
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
TEST ,
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
OTHER
Pt
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ai NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY gi OTHER TYPE INDEMNITY ❑ BOND ❑
INSURANCE WNVER I:manna Oat the licensee does not have the insurance adage required by Chapter 142 of the
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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 accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Ivy,°two Kit c +�t kt c i LICENSE*
G1 G�'PJ SI
J
MP Z , iJ ter CORoWATIACN p# PARTAERSHP sic Os
COMPANY NAME Co e CA a Mi11 rift 14.11Q 17 L l2 s ADDRESS TO C Rain h te. vt 'L-►(1 h�Vi/et-it-3
LGACITY S(9 Q..'n-.0 f STATE M (A ZIP 0 �0 TEL a I • 5'5 2 5
FAX V CELL EMAIL-TWA c Cc r.>..e ( c�. d 1rEr1a StviepiLAyyt to(L L;:'
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