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HomeMy WebLinkAboutP-4-542 C\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY[Yarmouth MA DATE 1/11/13 PERMIT# !/7 viz JOBSITE ADDRESS/ Rainbow Rd. ( OWNER'S NAME�Bnan Serpone 1 P OWNER ADDRESS[Same I TEL !FAX[ 1 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 ,EDUCATIONAL 0 RESIDENTIAL;,, PRINT ,` CLEARLY NEW Q RENOVATION:W REPLACEMENT:0 • PLANS SUBMITTED: YES 0 Nop IP FIXTURES 1. FLOOR—, • ' BSM 1 2 3 4,.. 5 - 6 7 - 8 8 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE ''' 't a....._ xr.Y:�..rrex ww• vYat�.,r.:a Bair x01.2.44011(411: DEDICATED SPECIAL WASTE SYSTEM > DEDICATED GAS/01L/SAND SYSTEM DEDICATED GREASE SYSTEM e r S, d 1 ,� - uA'.._-..1 .... �• ..A.. DEDICATED GRAY WATER SYSTEM _ a ; DEDICATED WATER RECYCLE SYSTEM H DISHWASHER } 1 w k ' _y 1 DRINKING FOUNTAIN 1 FOOD DISPOSER • ''s a FLOOR/AREA DRAIN 3 i INTERCEPTOR(INTERIOR) 4 - 1 '— 1 e is v 1 e KITCHEN SINK • 1 LAVATORY _ __ 1 r _:,.�,.. .: Y ,�.: .: iiing c ROOF DRAIN SHOWER STALL 1 i 1, • SERVICE I MOP SINK '. TOILET 1 i URINAL • R r WASHING MACHINE CONNECTION n• 4 R a •. Y� _ !. WATER HEATER ALL TYPES WATER PIPING , OTHER -- a.a __.'� simisi y` ) .` l�" iv "yrC t iii_..iV D? INSURANCE COVERAGE: I YtEhtigNI have a current liability Insurance policy or its substantial equivalent which meets the requirements of M•L h. rE IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL A LIABILITY INSURANCE POLICY la OTHER TYPE OF INDEMNITY 0 BOND 1,„4„1 By. ILDUN #PFJ ENT OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the 00J0•CG 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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME!Rick Whittle 'LICENSE#[11648 I SIGNATURE MPO JP© CORPORATION D# ,,, PARTNERSHIP©# LLC0#L .•__: J COMPANY NAME!R.H.Whittle Plumbing and Heating I ADDRESS`67 Owl Pond Rd. ClTYiBrewster ISTATE I MA 1 ZIP[02631 I TEL 508.255.9223 1 FAX [ mom» CELL 11774.722.1020 I EMAIL !sbatpower@comcastnet [ Z.2 / Nay+. cp-`.v'°`t afro it/ 0 /2177-41/ i �•