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HomeMy WebLinkAboutBLDP-18-004977 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rt: +li . rg CITY YARMOUTH MA DATE 3/8/18 PERMIT# BLDP-18-004977 i JOBSITE ADDRESS 150 GREAT WESTERN RD OWNER'S NAME HAYS JOHN L P OWNER ADDRESS HAYS DEBORAH A 150 GREAT WESTERN RD SOUTH YARMOUTH, TEL MA 02664-2205 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:m PLANS SUBMITTED: YES❑ NO m FIXTURES 1 FLOORS—) RSM 1 2 3 4 5 6 7 8 9 10 11 12 , 13 14 BATHTUB - CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ;DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA Do (INTEINRIOR) at KITCHEN SINK 1 LAVATORY 1 ROOF DRAIN SHOWER STALL • M SERVICE/MOP SINK ,� TOILET 1 URINAL kWASHING MACHINE CONNECTION 1 WATER HEATER WATER PIPING OTHER OTHER DESCRIPTION: il‘Pb INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES© NO 0 I'\ 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 of 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. PLUMBER'S NAME James Pazakis LICENSE PPL-15030-M I SIGNATURE MP MI JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# J COMPANY NAME JM PAZAKIS, INC. ADDRESS [447 Old Chatham Road CITY South Dennis STATE MA ZIP 02660 TEL 5083853677 FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NO ES Yes No I •1 3-13-/70 _/� '- THIS APPLICATION SERVE AS THE ❑ KA 6 (N�� DCD\\IT /{J FEES$ PERMIT It PLAN REVIEW NOTES