HomeMy WebLinkAboutBLDP-19-002577 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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C(TY South Yarmouth MA DA 18 PERMIT# 'L /R'C W,
JOBSITE ADDRESS 101 Phyllis Drive el 19 ( OWNER'S NAME Jack Avery
OWNER ADDRESS Same TEL 978-490-4134 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:J RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXTURES'2 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN _ •
INTERCEPTOR(INTERIOR)
KITCHEN SINK •
LAVATORY _ I
ROOF DRAIN
SHOWER STALL I
SERVICE I MOP SINK
TOILET I
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES
WATER PIPING
OTHER
REYEIVED
INSURANCE COVERAGE:
I have a current liability insurance policy cc its substantial equivalent which meets the requirements of MG_Ch.1q;„?;ES�1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Ull.• y LU I
LIABILRYINSURANCE POUCY o OTHER TYPE OF INDEMNITY 0 BOND 0 a, �i /'" E
a
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massach • Gen- •1 •ws,and that my si. .tore on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF s ER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application we true and acuate to the best of my knaMedge
and that all ettsplumbing Plum and Code and hapten ufthethe npermit L Issued for this application will be in•� arbnen�j
provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Lava.
PLUMBER'S NAME Scott Reid UCENSE#PL16354-M SIGNATURE
MP a JP 0 CORPORATION 0# PARTNERSHIP❑# LLC j]# 82-2993476
COMPANY NAME SR Plumbing ADDRESS PO Box 222
CITY Harwich Port STATE MA ZIP 02646 508-241-3773
FAX CELL EMAIL SRPLUMBINGLLC@GMAIL.COM
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