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HomeMy WebLinkAboutBLDP-19-000573 1 rrt MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4,/ air a-a CITY Yarmouth MA DATE 7-24-18 PERMIT# 4P'i-000173 =J:1_ JOBSITE ADDRESS 34 Midstream Drive OWNER'S NAME Bob and Ellen McDonough P OWNER ADDRESS 34 Midstream Drive TEL 508-694-6659 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 9 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ N09 FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i1 _ _ . . . ,_ � _ CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM1 r 'I� DEDICATED GASIOILISAND SYSTEM — `I� DEDICATED GREASE SYSTEM (0 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEMa � —`1—' DISHWASHER - - - — --__ s. DRINKING FOUNTAIN _ �_i 1 . FOOD DISPOSER I FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) ._____11o_,,_ KITCHEN SINK LAVATORY - - — -- - I ROOF DRAIN SHOWER STALL �' ' SERVICE I MOP SINK I i TOILET - URINAL 'a -- —211-'---INC-a- - - ---,-- ____ - — _, WASHING MACHINE CONNECTION ,a. _v — . —'—L.- — — — —y-2 WATER HEATER ALL TYPES 1 WATER PIPING OTHER =____ _____ _ r _—-s___ — —_, -- ��., —e . — I .--- - 1 - — -- — — INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 9 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILR Y INSURANCE POUCY 9 OTHER TYPE OF INDEMNITY 0 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 0 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 to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will bein compliancewith a Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME David Simmons LICENSE# 16259 SIGNATURE MPD JP❑ CORPORATION❑# PARTNERSHIP❑# LLC Q# 3975 COMPANY NAME Devlin Simmons LLC ADDRESS 4 Jeannes Way _ CITY Forestdale STATE MA ZIP 02644 TEL 77 137A42 7 V t L) I FAX CELL 508-648-2080 EMAIL DevlinSimmonsLLC©gmail.com @s 1JUL 25 2416 e---Rot �-7..._----------- " • g bi)7 1 and •