HomeMy WebLinkAboutBLDP-19-000847 k. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
;` CITY I Yarmouth I, MA DATE g-/3 - IV PERMIT#iL i9'f9N0•
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JOBSITE ADDRESS I re, /S at/d/i G y /[D. I OWNER'S NAME I AL, cA-'v64 4 O,dL y
P OWNERADDRESS:I ITEL:I IFAX:I I
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Ir.
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:@ -' PLANS SUBMITTED: YES 0 NO[V
FIXUTRES 1 FLOORS-• Bunt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER /
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK / e l _l , r- e
LAVATORY
ROOF DRAIN
SHOWER STALL 4H1- 3-1:#1u- r r
SERVICE I MOP SINK
TOILET hr, c4L.„c; I
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URINAL _"Y : ._0D :=./_
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 134 0
If you have checked yis,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 111/ OTHER TYPE INDEMNITY 0 BOND 0
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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 submttted(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. /�/d4
PLUMBER NAME I A/egg/too fifer-gF ILICENSE ft y/yr/,S-" SIGNATURE
COMPANY NAME I/?4477E'L,/- /lf.5/ I ADDRESS:I ? "Lar4t w' ,fl/-C ds? I
art:I #,C4Gd/G,V ISTATE: Mal ZIP: 1oievs— I FAX I
TEL: it CELL:ISba37,2.S1•2IEMAIL:!fery, 'GJ-/x,469 a) Cont astit, #V# 7 I
MASTER 0 JOURNEYMAN❑ CORPORATION 0# PARTNERSHIP❑#1 I LLC❑#
70 U?WW
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ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No Fp/249.
THIS APPLICATION SERVES AS THE PERMIT 0 0 _ /9�
FEE: S PERMIT# 01( '/
PLAN REVIEW NOTES 71/ ! /
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A