HomeMy WebLinkAboutP-18-171 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• 4(_<f CITY YARMOUTH _ , MA. DATE 07/06/2017 PERMIT#42/2P-8159r)17)
JOBSITE ADDRESS 58 PUTTING GREEN CIRCLE OWNER'S NAME I BALLOU
P OWNER ADDRESS: SOUTH YARMOUTH TEL FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL 0 .
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO El
FIXUTRES 7 FLOORS—. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 2
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIIJSAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY 3
ROOF DRAIN
SHOWER STALL 1
SERVICE I MOP SINK
TOILET 2
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES j NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE 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
CHECK ONE ONLY: OWNER 0 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 applica n will be in compliance all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • .
PLUMBER NAME: LEON E CLARK,JR. LICENSE# 11734-M SIGNATURE
COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: MA ZIP: 02660 FAX: 508-385-9177
TEL 508-385-8868 CELL: 508-367-1452 EMAIL:
MASTER 0 JOURNEYMAN❑ CORPORATION❑] # PARTNERSHIP❑# LLC❑#
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