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BLDP-19-001927 /P47 •-- a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK taw �7 CITY Yarmouth MA DATE 10/1/2018 PERMIT# A' r sem~JOBSITE ADDRESS 8 Captain Dore Road OWNER'S NAME Diane Russ P OWNER ADDRESS Same TEL 508-398-2932 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL D PRINT CLEARLY NEW:❑ RENOVATION:Cl REPLACEMENT:D PLANS SUBMITTED: YES❑ NOD FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB i ._. ,I . i ,_ I ; , it 1 !, CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM _ y4 I I I I ° ,i DEDICATED GAS/OIL/SAND SYSTEMst _s,..,...-..___ , DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM gill i �Irots DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ffsaima , + FOOD DISPOSERr. I in u� MIK_ al= FLOOR/AREA DRAIN , R' a` INTERCEPTOR(INTERIOR) �� fa ----1 MI i KITCHEN SINK l Si41 , _ a,n_ LAVATORY I� ' � �'i i ill . � 'LGS� 1�as ROOF DRAIN a a SHOWER STALL r 'lsS.ot. UI SERVMOPSINK � I� rURINAL r � i � WASH ING MACHINE CONNECTION """ WATER HEATER ALL TYPES WATER PIPING 1 11111 i'r j ,, ,, , ,, , I it ,,r- :, 11 ii ,, "I i 1 it , li i, 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY Q 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 t• - •_ • my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co p •nce with all Pertinent provisio • the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME David P Lyons LICENSE# 11308 SIGNATURE MPD JPD CORPORATION D#2124C PARTNERSHIP©# LLCO# COMPANY NAME Lyons Plumbing and Heating INC ADDRESS 632 Cambridge Street CITY Worcester STATE MA ZIP 01610 TEL 508-845-1924 FAX CELL 508-868-3761 EMAIL lyonsph@verizon.netr EctNA-( ao-/ W-Isr