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Home My WebLink AboutP-14-117 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Or H3d1_ t /� // `�'__''�5=;� CITY YARMOUTH MA. DATE 08115/13 PERMIT# // JOBSITE ADDRESS 183 EILEEN STREET I OWNER'S NAME HENDERSON P OWNER ADDRESS: YARMOUTHPORT TEL 508-479-7860 FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:U] REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXUTRES 1 FLOORS Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER X DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK X LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING�i�� ICE MAK .,'tel r•.ate X fp Pa? I h ve dt� 7p13 INSURANCE COVERAGE Ore liasdity ins ante policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES LI NO 0 ,QTMENS f y/ • :Witt QIt • . ndicate the type of coverage by checking the appropriate box below. But; //Irk Br- UABILITY INSURANCE POLICY ❑O OTHER TYPE INDEMNITY 0 BOND 0 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 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 Maccachusetts State Plumbing Code and Chapter 142 of the General Laws. �2 ��Ah/iJJ PLUMBER NAME: LEONE CLARK,JR. I LICENSE# 11734-M SIGNATURE— COMPANY IGNATURECOMPANY NAME: I TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE • CITY: SOUTH DENNIS STATE MA ZIP: 02660 FAX 508-385-9177 TEL: 508-385-8868 CELL: 508-367-1451 EMAIL MASTER U] JOURNEYMAN 0 CORPORATION❑] # PARTNERSHIP 0# LLC 0# /� L