HomeMy WebLinkAboutBLDP-19-000520 7d
--' AZ, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
u waLi- CITY Yarmouth MA DATE 712512018 PERMIT#/1/-PP'/9'000 i'
JOBSITE ADDRESS 18 Wildflower Ln. OWNER'S NAME Regan
POWNER ADDRESS same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:a REPLACEMENT:❑ PLANS SUBMITTED: YES❑ N00
FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 I 9 I 10 11 12 13 J 14
BATHTUB 'I i i
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM ' i
DEDICATED GAS/OIUSANDSYSTEM - -r - -- r -
DEDICATED GREASE SYSTEM _ y
DEDICATED GRAY WATER SYSTEM r r
DEDICATED WATER RECYCLE SYSTEM j
s.
DISHWASHER 1 `
DRINKING FOUNTAIN I i
FOOD DISPOSER 1
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR) ir r r
KITCHEN SINK 1 _
LAVATORY i tor
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL i ,
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING r r ;
OTHER water supply to fridge 1
If t r
INSURANCE COVERAGE: JI
I have a current liability insurance policy or its substantial equivalent which meets the requirements o MGL CtyJ}2.2'5S all ENO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX B LOW
UILDING DEPARTMENT
LIABILITY INSURANCE POLICY❑� OTHER TYPE OF INDEMNITY 0 BOND ry _ ----
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 .
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to i- best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co ' : •-.wi -sign of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Charles Stockdale LICENSE# 24526 r SIGNATURE
MP JP CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME Charles Stockdale ADDRESS 256 Mayfair Rd.
CITY S.Dennis STATE MA ZIP 02660 TEL 508-398-2843
FAX CELL 508-208-1613 EMAIL
G,1}"
I -
• .
1-
• 4
, •
• r
•
•
- /
eig77:8 -
en:2 -qt
.1 • • -•
44
6)2 d