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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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`-=""" it/� CITY YARMOUTH 1 MA DATE Lzr/-/g, PERMIT P I?'00 dire
JOBSITE ADDRESS Laza / /yul Si act Lane. f OWNERS NAME p/Z Aryl/1/4/
OWNER ADDRESS TEL FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIALEl
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOS
FIXTURES 1 FLOOR-4 SSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB Q
CROSS CONNECTION DEVICE + ! -
DEDICATED SPECIAL WASTE SYSTEM 4 1 _ ._I
DEDICATED GAS/OIL/SAND SYSTEM �;': 7 S
DEDICATED GREASE SYSTEM J •
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM Y 1
DISHWASHER r
_
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR IAREA DRAIN
INTERCEPTOR(INTERIOR) b
KITCHEN SINK a _ n
-- LAVATORY
ROOF DRAIN ' _ R
SHOWER STALL
SERVICE I MOP SINK
TOILET ,• _ '_
URINAL d
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES f
•L..IJ.1.... .. . .._. .. .._. .` A...__ ««. ♦..,,�., r Imo, s _....,. .. ..
WATER PIPING ' a
1
OTHER •
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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 Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY Q 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 ❑
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 t• best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co • ance with all P.din: t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •
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PLUMBER'S NAME KEVIN LAMOUREUX LICENSE# 15383 or I N.TUR
MP JPO CORPORATION❑# PARTNERSHIP❑# LLC®# •
COMPANY NAME LAMOUREUX PLUMBING ADDRESS 61 JOBYS LANE 1
CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068
FAX 508-420-7992 CELL 508-292-5085 EMAIL lamoureuxplumbing@verizon.net
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ .,_ 9ij
• FEE: $ PERMIT# /o0
PLAN REVIEW NOTES
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