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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
__"— c CITY Yarmouth MA DATE 0 07/00 PERMIT ItAtIVIILOCVng
JOBSITE ADDRESS 216 Winslow Gray OWNER'S NAME Lashio Mose
POWNER ADDRESS[216 Winslow Gray TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL G
PRINT
CLEARLY NEW:❑ RENOVATION:a REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES 2 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE .--_,
DEDICATED SPECIAL WASTE SYSTEM • A I M sr „J, I '
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM — 4 _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 4____-1/4,_ — ---.� Y
DRINKING FOUNTAIN
FOOD DISPOSER '
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) r i
KITCHEN SINK _ _
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK 4
TOILET ' 1 1 l If '. _ - a
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES _ _
WATER PIPING
OTHER 1. 1 _ _ _
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING NE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY❑ 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.
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are hue and - - . i e• nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co... ce with all Pertinent provision. the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Virgilio Silva LICENSE# 31395-J hNATURE
MP❑ JPQ CORPORATION❑# PARTNERSHIP CP LLC I:1#
COMPANY NAME Silva Plumbing&Heating ADDRESS 155 Sudbury Lane
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CITY Hyannis STATE MA ZIP 02601 I TEL 1
FAX CELL 774-836-0176 EMAIL Ivirgiliomga@hotma'.com b (.. tE IV F I. 1 I , 'r
JUL 09 2018 i 1 1 F1'
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