HomeMy WebLinkAboutBLDP-19-001484 .14, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
tip:. CITY Yarmouth MA DATE 917118 PERMIT#/✓ i/7 -ovi �4
JOBSITE ADDRESS 48 Suffolk Road OWNER'S NAME Luke,Chantal
5oJ) OWNER ADDRESS Same TEL 774-836-0898 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL C] EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:] PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB r
• CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM �,
DEDICATED GASIOIL/SAND SYSTEM
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DEDICATED GREASE SYSTEM '
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DEDICATED GRAY WATER SYSTEM m,i1
DEDICATED WATER RECYCLE SYSTEM ;
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DISHWASHER ,
DRINKING FOUNTAIN .1a,
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FOOD DISPOSER ,
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) gir wa,
KITCHEN SINK
LAVATORY SI
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DRAIN
SHSTALL
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TOILET
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_WASHING MACHINE CONNECTION allaWATER HEATER ALL TYPES
WATER PIPING
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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❑ 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. 7?CLst4R
PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 7 SIGNATURE
MPQ JP CORPORATIONQ# 1762-C PARTNERSHIP❑# ac 0#
COMPANY NAME Rusty's,Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA ZIP 02673 j TEL 508-775-1303
FAX 508.771-9310 CELL EMAIL mburke@rustysinc.com
926990 0
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