HomeMy WebLinkAboutBLDP-19-002075 J*, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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v°EI_ CITY YARMOUTH , MA. DATE 1012118 PERMIT#0-Dpf'VZ476--
JOBSITE ADDRESS 94 WHARF LANE OWNER'S NAME WATANABE
P OWNER ADDRESS: YARMOUTHPORT TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0 "
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO
FIXUTRES 7 FLOORS-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE 1
DEDICATED SPECIAL WASTE SYS
DEDICATED GASIOILISAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK \.
TOILET
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 0 NO 0
If you have checked YES,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 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 applicati will be in compli ce with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Cf
PLUMBER NAME: LEON E CLARK,JR. LICENSE# 11734-M SIG ATURE
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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: karen@tcplumbing.net 1
MASTER 0 JOURNEYMAN 0 CORPORATION 0# PARTNERSHIP 0# LLC❑#
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