HomeMy WebLinkAboutBLDP-18-003261 Unit 605 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—=nL—° _ CITY W Yarmouth MA DATE 10/17/2017 PERMIT# 13A1V- f V fl6Q
op% JOBSITE ADDRESS 345 Camp St#605 OWNERS NAME Charles White Management
OWNER ADDRESS Same 1 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:d PLANS SUBMITTED: YES❑ NO❑Q
FIXTURES 7 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB a I I S S!SI I 51 I S
CROSS CONNECTION DEVICEMSMINV ; 1a11.11in.
DEDICATED SPECIAL WASTE SYSTEM 1 [ 'QSIii1r all. .01.1011.
DEDICATED GAS/01USAND SYSTEM .
DEDICATED GRAY WATER SYSTEM E ,__ ( ,
DEDICATED GREASE SYSTEM
DEDICATED WATER RECYCLE SYSTEM [MF _; r [�� �_�_._ ',
DISHWASHER MISTS - 7—
DRINKING FOUNTAIN � nit
FOOD DISPOSER
FLOOR/AREA DRAINQM_ 0�i�r�,� �
LKITCHEN AVATORYIINTERCEPTOK(INTERIOR) I—I c_ittannar
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ROOF .n .a,
ROOF DRAIN IMISOMEMOSIMMESSSOICS
SHOWER STALL I
SERVICE/MOPSINK d ( 1 (��
TOILET
URINAL I I ,
WASHING MACHINE CONNECTION ML
WATER HEATER ALL TYPES
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WATER PIPING
OTHER BACK FLOW
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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 a NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 0
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. YN!/'.K y n4 . � -
PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 !l SIGNATURE
MPU JP❑ CORPORATION El# 1762-C PARTNERSHIP❑# ac 0#
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL ssavery@rustysinc.com
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