HomeMy WebLinkAboutBLDP-17-005717 T , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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I f- y CITY G�'Y�✓V1/�d MA DATE PERMIT#/'�!-OP-/7-ae)57/ �
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JOBSITE ADDRESS 5 i-4 �'Wi - - - 6- OWNER'S NAME i t.:' ' GVUt- ' �J
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAVG EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES FLOOR-, BSM 1 2 3 4 5 8 7 S 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
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
TOILET
URINAL -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING....._...._.. ..
OTHER
INSURANCE COVERAGE:
I have a 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 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 I
SIGNATURE OF OWNER OR AGENT
I hereby certify thirila the details and Information I have submitted or entered regarding this application are true and accurate t of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in corn a P nt provi n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME TIM MCELROY .('LICENSE# 15993 f
URE
MP r JP CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME CAPE COD MASTER PLUMBERS, INC, ( ADDRESS. 70 CRANBERRY HWY P.O.BOX 756
CITY SAGAMOR
E f STATE MA.. ZIP 02561 TEL 508.317-5525
FAX CELL EMAIL