HomeMy WebLinkAboutBLDP-18-005928 woo l/MA
_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '
r.=ifs-a
ae�4= CITY; lJti.? _ _MA DATE: _ 2 T .I.� PERMIT# /"^/5-QJo'��
JOBSITE ADDRESS ' OWNER'S NAME! L_n .rf- , ` ,(J)
POWNER ADDRESS -_ YO,,rr,c TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I f RESIDENTIAL
PRINT •
; �
CLEARLY NEW: RENOVATION:1 .' REPLACEMENT: PLANS SUBMITTED: YES NO; .
1
FIXTURES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB :... W 1,-- ,
CROSS CONNECTION DEVICE a
DEDICATED SPECIAL WASTE SYSTEM _ I ) . 1 '
v
DEDICATED GAS/OIUSAND SYSTEM :
DEDICATED GREASE SYSTEM : =
DEDICATED GRAY WATER SYSTEM l. ;=-
DEDICATED WATER RECYCLE SYSTEM 1 i
._ i..
DISHWASHER E 3 `
DRINKING FOUNTAIN
t i I
FOOD DISPOSER
FLOOR/AREA DRAIN _ ' -
INTERCEPTOR(INTERIOR) ' _.. '.. ._ __ .. _ '-- -
_KITCHEN SINK # ' _
LAVATORY ' - I
i,,._._ ._f ,
ROOF DRAIN ..1
_SHOWER STALL I ,l ; a
SERVICE/MOP SINK
;
TOILET
URINAL I 3. i
WASHING MACHINE CONNECTION ' : 4
_WATER HEATER ALL TYPES
WATER PIPING {
,� s
OTHER
.
1:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES . NO L_m'
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY'1' 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 _;
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 - d - cura - • h est• owledge
and that all plumbing work and installations performed under the permit issued for this application will be in co . :nce ith - e p • . Hof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1
PLUMBERS NAME DAV_E PLUM LICENSE# 15760 SIGNATURE
MP! , i JP! , CORPORATION v:/ti 3267 _ :PARTNERSHIP: `# _ ,LLC'__ i#'
COMPANY NAME CAPE ASSOCIATES INC ADDRESS'PO BOX 1858
CITY N EASTHAM STATE MA ' ZIP .02651 TEL'5082551770
FAX .5082401473 CELL 7748360930 EMAIL ,DPLUM@CAPEASSOCIATES.COM
477)
N �-
' � ��
��
�\
�.