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HomeMy WebLinkAboutBLDP-19-001067 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t1 -t CITY Yarmouth MA DATE 821/2018 PERMIT# 1)-5'0/616/ JOBSITE ADDRESS 34 West Woods OWNER'S NAME Ayers P OWNER ADDRESS Same TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NOD FIXTURES 1 FLOOR-, BSM 1 I 2 3 4 5 6 7 I 8 I 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM —�- - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER t DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN - INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL r _ _ _ SERVICE/MOP SINK TOILET URINAL - -- - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ _ WATER PIPING OTHER [ice maker 1 -. _ _ _ _. - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑+ OTHER TYPE OF INDEMNITY❑ BOND❑ 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 an• V •= bes if my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in • •lian�� l ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /, /. t;� PLUMBER'S NAME Charles Stockdale _ LICENSE# 24526 SIGNATURE MPD JPQ CORPORATION❑# PARTNERSHIP❑# LLC D# _ COMPANY NAME Charles Stockdale ADDRESS 256 Mayfair Rd. CITY S.Dennis STATE MA ZIP 02660 TEL 508-398-2843 FAX CELL 508-208-1613 EMAIL f` :i P- 5 e l ( AUG 222018 D Isunk -ofMNT i , • it7 l