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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY I Yarmouth // sir
— I. MA DATE .3-��-13 PERMIT# , 3"(p V V
JOBSITEADDRESS I I OWNER'S NAME I BOGS/ii -j4}y 7,s- I
P OWNER ADDRESS:1,4-if (hit Rf_p2407 ,Ca- 1TEL:k - j�q,[JFAXl I
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDTUL�'�J
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[$� PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 7 FLOORS-, en I 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSSCONN DEVICE
DEDICATED SPECIAL WASTESYS S3
DEDICATED GAS/0SDSYS
DEDICATED GREASE SYSEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING
OODWASTE
GRIND
FOUNTAIN
FOOD DRAIN NR
INTERCEPTOR
AREADRAIN
TCHESINK INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE IMOP SINK
TOILET
URINAL
WATER G HEATER NE
CONNECTION
WATER PIPING ALL TYPES I
WATER PIPING
I have a current liability insurance policy or its substantial equivalent which INSURANCE eAGE
meets the requirements of MGL.Ch 142 YES 0 NO iir
If you have checked g,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
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0 I.
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NC AIVER:I am aware that the licensee(K.: L' ,..,.= the insurance coverage required by Chapter 142 of o
1_,:r.= ' . . ,, . • , on this i , application w .4n this requirement — "' o
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#�/„moi
CHECK ONE ONLY: OWNERM.1 I
f•E 0 OWNER-,• .: AGENT 0 C:_7 \ 3
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I hereby certify that al of the details and Information I have submitted(or entered)regarding bis application are true and accurate to the be _ _
Knowledge and that all plumbing work and Installations performed under the permit Issued for this appl p will be in compliance with all Pertinentcti
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Lan / _,L
PLUMBER NAME / �! I LICENSE#I I4S 7 ')OI `7l TLP^ SIGNATURE
COMPANY NAME: IG O M Y4' A /'I r ADDRESS: . s. 4 /
CflY:I nl..v-, . 4P-1-34— I STATE: 175974 ZIP. I a., /, 7j FAX: I I
TEL:WD?f' 75-0 771 CELLI Iemit I
MASTER❑ JOURNEYMAN CORPORATION❑#I I PARTNERSHIP❑#I I LLC❑#I
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?LG. BELOW CE USE ONLY FINAL INSPECTION NOTES
ROUGH�!INSPEI'�!nN NOTES
Yes No
TM!S APPLICATION SERVES AS THPRMIT
E E
0 0
FEE: S PERWTt----_
PLAN REVIEWNOTES
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