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PHONED CAC RETURNED0 WANT TO. WILL CA 111I WAS INI�y% UT0
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ItN` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.liir- CITY I Yarmouth I, MA DATE I J31A/. /y, so/,3 !PERMIT# /9/.7 — / .
JOBSITE ADDRESS 1,2-7 z7 /{aGtX.ry4 PR/VC I OWNER'S NAME I T'u'Rec. I
P OWNERADDRESS:I ITEL:I 1FAX:) I
TYPE
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
CLEARLY NEW:0 RENOVATION:V REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXUTRES 7 FLOORS emt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE -
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT •
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK _
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES '
WATER PIPING
P' fru"62 /
ICG ,iAKfp /
COVERAGE
I have a current liability insurance policy or its substantial equivalentOE whi which meets the requirements of MGL Ch.142 YES a NO 0
If you have checked 10,please indicate the type of coverageve/by checking the appropriate box below.
LIABILITY INSURANCE POLICY L� 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 waive this requirement
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
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 petard Issued for this application will In compli ce ' all Pe ' t
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME I MIA/C. b'4 . %O g I LICENSE#1 3(Sdz/ I SIGNATURE
COMPANY NAME I int4rito5 P 1 K I ADDRESS:12/0 guA/77,v& tit
CITY:I p. %fr,udum' I STATE: illy ZIP: 1 02-6 7 Z I FAX 1 I
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❑ JOURNEYMAN IuI CORPORATION❑#I • I PARTNERSHIP❑#1 I LLc❑#I I
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