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S,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
as'� CITY Yarmouth MA DATE 1/1712018 PERMIT# P Y-ar /007
JOBSITE ADDRESS 51 Winter Street OWNER'S NAME Dave Shaw
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL El
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CLEARLY NEW:0 RENOVATION:Q REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB a
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM r
DEDICATED GRAY WATER SYSTEM IN I!'U!
,
I i
DEDICATED WATER RECYCLE SYSTEM l i 1
DISHWASHER
DRINKING FOUNTAIN . inFOOD DISPOSER ri
_
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) r f
KITCHEN SINK
LAVATORY I 3 j mia !
III-
ROOF DRAIN M Mt ='
SHOWER STALL I--
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION , 1 r. r
WATER HEATER ALL TYPES
WATER PIPING r '` ,r
OTHER JLAUNDRY SINK -1 i 1 d dI I. i' l
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ 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
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 to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be inanc t ine f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME Peter J.Hassett LICENSE# 11682 SIGNATURE
MPD JPD CORPORATION#-3506 PARTNERSHIP❑# LLCOtt
COMPANY NAME Hassett Plumbing and Heating,Inc. ADDRESS 8 Skipper Lane
CITY Yarmouth Port STATE MA ZIP 02675 TEL 508-744-7555
FAX CELL 508-237-2175 EMAIL hassett357m@msn.com
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