HomeMy WebLinkAboutBLDP&G-18-006682 r �+► MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
} CITY GI�'12�/1/1.61ti T'- ' MA DATE PERMIT#4 '84—
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JOBSITE ADDRESS 3 2 Taq w1-ctivx-A ec OWNER'S NAME I ''vv (-'-. `l^ ✓/
OWNER ADDRESS TEL 1 6 5),S ... .:FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL X;
PRINT •
CLEARLY NEW: _ RENOVATION: REPLACEMENT:.k' PLANS SUBMITTED: YES . NO
FIXTURES'2 FLOOR—, BSM 1 2 3 4 5 5 7 8 9 10 11 12 . 13 14
BATHTUB : .. . _ r .. . . _. ...., ,
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM i : . ... . _
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM . ,T.., .. .. :...,. . -..
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOODDISPOSER . ... . ._ ... _,.. .. . ..._ ,.,. .. .. .. .. ... ., z....;, �,...._ . . _ . ..._... ..-... _.
FLOOR/AREA DRAIN •R
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY . ..._ ._ ,., . _ ... . ., .. __... ' _.... . ....... . .,. ..,.. . .,:., _ •
.. ._.. ., . . ....
ROOF DRAIN -.
SHOWER•STALL _.r. •...,_. .. ,.. .
.SERVICE I MOP SINK
TOILET
URINAL - .. ,... , ...._.. ..._.. .... . ,.. .....-. _... . ...... .._,.. .�._... _. _. .. ..._ . ..._ . - .
WASHING MACNINE CONNECTION
WATER HEATER AL.TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
h have a current liability hnsurance policy or its substantial equivalent which meets the requirements of Mel-Oh.142. YES 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 E .
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of Ike details and inforrnat1 lI have submitted or entered regarding this application are true and scours t of my knowledge—
and that all pkenbing work and Installations performed under the permit issued for this application will be in corn iI nt provi n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME TIM MCELROY I LICENSE# 15993 URE
MP v JP CORPORATION .# PARTNERSHIP :# LLC #
COMPANY NAME CAPE COD MASTER PLUMBERS,INC. ADDRESS•70 CRANBERRY HWY P.O.BOX 758
CITY SAGAMORE STATE IAA I ZIP 02561 _.. TEL'508-317-5525 , t
FAX CELL EMAIL
r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK
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111" CITY &4 v1 L/L2 1 1-' MA DATE PERMIT# ":-/)/1/ `CC1( e,Z
JOBSITE ADDRESS Ted YVL v IQ I�WNF,R'S NAME I\✓h C 1A.Y1 t l
G OWNER TEL :2 ICJ 7-5 5 2 S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES FLOORS-+ BSM 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/SPACE HEATER
ROOF TOP UNIT
TE$T r
UNIT HEATER
.UNVENTED ROOM HEATER
WATER HEATER _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch,142 YES Li NO ❑
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement,
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate t f my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compli pro
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME `TkYYt M c-6-1 LICENSE
MP MGF❑ JP 0 JGF 0 LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Ct -t'. (:e 3 A$ A. P/U.Y .laaDDRESS $ 0.11241-ytr wru 1-itykAArkk
CITY _ STATE 1 Y vt 4A ZIP °A I CI I TEL (cos) a p - 55 a 5-
FAX CELL EMAIL
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