HomeMy WebLinkAboutP-18-179 — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
� srr CITY YARMOUTH , MA DATE 7/11/17 PERMIT# BLDP-18-000179
JOBSITE ADDRESS 984 WEST YARMOUTH RD OWNER'S NAME NOTEVA TANYA Z
P OWNER ADDRESS 150 DEPOT ST DENNIS PORT,MA 02639 Jl'EL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW: El RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOORS-4 RSM 1 , 2 , 9 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE _
DISHWASHER 1 _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
WATER PIPING 1
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES N NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW .
LIABILITY INSURANCE POLICY m OTHER TYPE OF INDEMNITY 0 BOND 0
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.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all or 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 all Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Mark Hazleton LICENSE#3732 SIGNATURE
MP !9 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Mark A Hazleton ADDRESS 275 MEIGGS BACKUS RD
CITY SANDWICH STATE MA ZIP 025632750 TEL
FAX CELL EMAIL
ROUGII PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVE AS THE 0 0
Dr WAIT
FEESS PERMIT#
PLAN REVIEW NOTES I A//q//,
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