HomeMy WebLinkAboutBLDP-18-007297 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
tit,zPi CITY Yarmouth MA DATE 06/25/2018 PERMIT# it fr' !e'er,7.4dr
JOBSITE ADDRESS 34 Lookout Rd OWNER'S NAME Kevin Ryan
P OWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL '
PRINT
CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR–, BSM 1 2 3 4 5 67 8 9 10 11 12 13 14
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CROSS CONNECTION DEVICE
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11111,1. III. NIP ,
DEDICATED SASICATED PECIAL SAND SE STEM SYSTEM n l _ i W
DEDICATED GREASE SYSTEM ,t
DEDICATED GRAY WATER SYSTEM ,
DEDICATED WATER RECYCLE SYSTEM I ; r, -1 ,I
DISHWASHER
DRINKING FOUNTAIN j IIFOOD DISPOSER 111
INTERCRintilitillirin, 1 i
FLOOR EPTEA OR
INTERCEPTOR(INTERIOR)
KITCHEN SINK N m n r
LAVATORY
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ROOF DRAIN
SHOWER OLL � r
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SERVICE I MOP SINK
TOILET
URINAL 111 2 a Rte,
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WASHING MACHINE CONNECTIONTL'1
"ii WATER HEATER ALL TYPESIL I
WATER PIPING
OTHER I I
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INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY Q OTHER TYPE OF INDEMNITY ❑ BOND 9
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 9
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 compl'ance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME JASON DREW LICENSE# J-30715
SIGNATURE
MP❑ JP❑ CORPORATION❑#PARTNERSHIP❑#® LLC❑#
COMPANY NAME DREWS PLUMBING ADDRESS 6 AGASSIZ ST
CITY BREWSTER STATE MA ZIP 02631 TEL 508-360--4W
FAX CELL I EMAIL - N 25 7018
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