HomeMy WebLinkAboutBLDP-18-002238 •
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MASSACHUSETTS UNIFORM APPLICATION FOR A R IIT TO PERFORM PLUMBING WORK q
'SrCITY yfr _g `✓ xUt MA DATE PI1' 1PER #1,"/(.0 ti' 0O�7D
JOBSITE ADDRESS SOSA. WNE 'S NAME hk
P OWNER ADDRESS ' ' illi i L TEL FAX
TYPE OR OCCUPANCY TYPE : COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL UV
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PRINT
CLEARLY NEW:�RENOVATION:V REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
FIXTURES 1 FLOOR-" BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB Y
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _ •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER • 0%.)
DRINKING FOUNTAIN
FOOD DISPOSER V
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) t _ F. C r- it "- "^' t
241
_ KITCHEN SINK t I
LAVATORY 5 ;
ROOF DRAIN I � t
SHOWER STALL t +4
'SERVICE/MOP SINK �S�- q y )
isur� ZZ
i TOILET Y ",.._� - - '
UASHI •+' _ f
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
SURANCE COVERAGE:
I have a current liability insurance policy or its stantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE TH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF 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
11-1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acggqlll rate to the best of my knowledge
and that an plumbing work and Installations performed under the permit issued for this application will be in compliance w�b.ai Pertinent provision of the -
Massachusetts State Plu rng Code and Chaptr 142/ of the General
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PLUMBER'S NAME /G'"► v Dr/I t rdc dO t/ttICE14# l!J- QSIGNATURE
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COMPANY NAME/ha-ter/J ,� ,ifi+M �/A�DDRESS Z5 7i /l2U�/y� /� 2
CITY 9 Zit (/ V L STATE p(4-zip D2l iS TELt/2S�e0 . q5
FAX CELL EMAIL
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YARMOUTH WATER DIVISION
99 BUCK ISLAND ROAD
WEST YARMOUTH, MA 02673
PH,: 508.771.7921
FAX: 508-771-7998
BUILDING PERMIT APPLICATION
DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET
Bldg. Site Location Map #: Lot #:
Proposed Improvement: ail:-0 4,10„.,t it, 2a, r Ljh odacs _K newt //
Applicant: /� � �, /� / cc'Ail jan-CA
OW Ili 0-4-7er
AddressCzcciTel. r: p _ rYiv__3L Date Filed, . _--.32-1/7
RESIDENTIAL AND / OR COMMERCIAL BUILDING
Water Depa tn,ent: Determines Compliance o`Plater Avai'a5ility and or Ex.sting Location
Engineering Department: Determines Compliance for Parking and Drainage
Conse-vation Commiss'on: Determ'nes Compi ance to Wetlands Acts; i.e. IF Lot(s) Border an;Type a'
Wetlands, Streams, Ponds, Rivers, Ocean, Bogs, Bays, Marshland, Etc...
Health Department: Determines Compliance to State and Town Regulations, i.e., Requirements
for Septage Disposal and other Public Health Activities
Fire Department: Determines Compliance to State and Town Requirements for Persona',
Safety, Property Protection;, i.e. Smoke Detectors, Sprinkler Systems, Etc
S cne..re c'ap7:ra... ..
PLEASE NOTE:
COMMENTS:
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"s_t_1£_124 l,Joack _ IA)ILL...4. Co &,[2 h___gy le _Ar d cb
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Reviewed by: Water Division Date .
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