HomeMy WebLinkAboutBLDP-17-000753 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
z i_, CITY W.YARMOUTH 1 MA DATE 08-Q5-16 PERMIT#/'�;(1/a'/%-ea 0'7, es
JOBSITE ADDRESS 2 SANDY LANE 1 OWNER'S NAME[STEVE RHODES —��~ J
P $ OWNER ADDRESS Same J TEL 617-893-1371 ,i FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAL 0
PRINT
CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YES Q NO2
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE ' .i
DEDICATED SPECIAL WASTE SYSTEM i
DEDICATED GAS/OIUSAND SYSTEM t1 ;I.._..
DEDICATED GREASE SYSTEM .,. .. .I' . .. _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM i x ,
DISHWASHER
DRINKING FOUNTAIN 11
FOOD DISPOSER
FLOOR IAREA DRAIN .x._ �_._ ,..,-
i �' l
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY qi
ROOF DRAIN «. ..
'
SHOWER STALL . l_._. . . . i -..
SERVICE IMOP SINK
TOILET
URINAL ._._ • :__ ._.... ._
WASHING MACHINE CONNECTION I'S x __
WATER HEATER ALL TYPES 1
WATER PIPING
OT BACKFLOW '-li -- l
� r 2 S.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[a NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND Q
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 Q AGENT Q
SIGNATURE OF OWNER OR AGENT G
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, Ailt A4 q / ,,,,.�
PLUMBER'S NAME Frank W.Roderick ILICENSE# 17794 , J SIGNATURE
MP ai JP 9 CORPORATION 0#11762-C'1PARTNERSHIPLJ# -j LLCLi#`. ,. 441
COMPANY NAME Rus is Inc. ADDRESS 222 Mid-Tech Drive
4.44,
CITY West Yarmouth ISTATE MA I ZIP 02673 TEL 508.775-1303
FAX 508-771-9310 CELL 1EMAIL 1SELWOODd@RUSTYSINC.COM �� — 1
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