HomeMy WebLinkAboutBLDP-17-004469 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
M—._1— PERMIT# py n�",
-fit CITY `+�{,°' o"�'�i ii-✓I 1'1 i MAy DATE �/:?1//)'017 I /�' Q�Y—O ��/6 f
JOBSITE ADDRESS `j O 41 LII Viii Oil ` SC'OWNER'S NAME VC (Jr-,619I v1' 1 s( 1v&1
POWNER ADDRESS I TEL 7 0 7,S /f 1FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL ® RESIDENTIAL rid
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CLEARLY NEW:® RENOVATION:® REPLACEMENT:Z PLANS SUBMITTED: YES 0 NOIZ
FIXTURES 1 FLOOR—. BSM 1 2 3 4 1 5 6 7 8 9 10 11 12 13 14
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CROSS CONNECTION DEVICE —
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DEDICATED SPECIAL WASTE numegouripp011i
DEDICATED GAS/OIL/SAND SYSTEM am ._ , _I. I(_ y_: ..:. '
DEDICATED GREASE SYSTEM f�[lI ii IJ
DEDICATED GRAY WATER SYSTEM �Mili
.1111111121 DEDICATED WATER RECYCLE SYSTEM .- _ ,. I,NW � 1 WW
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DRINKING FOUNTAIN ppi imi wowiim1mumisag i;-1 .
FOOD DISPOSER 11111111 11111111WilliWIIMINIMPROPIROMIIIIIIIIIIIMINIC
FLOOR I AREA DRAIN 1M- ._ I I
INTERCEPTOR(INTERIOR) .. iiiiiiliiiiiiilillMW M 11111111
KITCHEN SINK NS11111111I 'iMI
LAVATORY OM_. f
ROOF DRAIN 11.11M11111111.10111M -.. -. l 1 — .
SHOWER STALL 1 . . J 1 [ '�.,
SERVICE 1 MOP SINK Mi.I MR I 1 i
TOILET mi p
URINAL M i I
WASHING MACHINE CONNECTION ( I_N � ,., .
WATER HEATER ALL TYPES A `imi—im t l , '.NS
WATER PIPING M I ..MINIMICIOSPIIIIIIIIMINIUU.
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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 Lid NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ® BOND Li
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 Li 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 st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance 'th all P t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME R PETER CHECKOWAY LICENSE# 13417 I URE
MPD JP❑ CORPORATION0# 4008 PARTNERSHIP[# ILLCD# I
COMPANY NAME BOURQUE HEATING&COOLING CO ADDRESS 1199 PITCHERS WAY t
CITY HYANNIS STATE MA ! ZIP 02631 TEL 508-790-2887
FAX 508-771-9696 I CELL 508-735-9993 !EMAIL infoca bourgeheatingandcooling.corn '
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1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ . PERMIT#
PLAN REVIEW NOTES