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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r. rYt " CITY YARMOUTH MA DATE 3/29/18 PERMIT# BLDP-18-005398
JOBSITE ADDRESS 6 SCOOP CIR OWNER'S NAME MURPHY CORAL A TR
P OWNER ADDRESS MURPHY FAMILY RLTY TRUST 6 SCOOP CIR YARMOUTH PORT, TEL
MA 02675
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El •
PRINT
CLEARLY NEW: 0 RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO
FIXTURES - FLOORS—, RSM 1 2 3 4 5 6 7 8 9 10 11 17 13 14
BATHTUB 1 _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE / _ _
DISHWASHER 1 1Q
DRINKING FOUNTAIN Y V
FOOD DISPOSER - 7//
FLOOR/AAREA DRAIN
INTERCEPTOR(INTERIOR)
_KITCHEN SINK 1
LAVATORY 1 1 0�,
ROOF DRAIN _ �O
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1 1 _ _
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
WATER PIPING
OTHER
OTHER DESCRIPTION: (,,
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES El NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY m 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.
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.
PLUMBERS NAME [Alex Braga LICENSE#5668 SIGNATURE
MP !9 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ALEX B BRAGA ADDRESS 2 MOUNTWOOD RD
CITY MARSTONS MLS STATE MA ZIP 026482111 TEL
FAX CELL EMAIL
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