HomeMy WebLinkAboutP-14-282 a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
i" Ng I CITY SOUTH YARMOUTH I MA DATE 10/21/2013 PERMIT# piq O z2
JOBSITE ADDRESS 844 ROUTE 28 UNIT 3D OWNER'S NAME BUTKEVICH BERNARD,JR
P s7 OWNER ADDRESS 1 KINGSBROOK WAY NORTH EASTON,MA 02356 I TEL 774-810-5122 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
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1 CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NOQ
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FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
cBATHTUB R II I II I 1 dI
CROSS CONNECTION DEVICE +{ Il . d I I
DEDICATED SPECIAL WASTE SYSTEM `I " I1 {I d I I - rh_ I� ,.
DEDICATED GAS/OIUSAND SYSTEM 1 (I — -III- I-'--' (1 it ,- ti iI }I y „ w
-- DEDICATED GREASE SYSTEM 1 1 1 _ _ y I W 1
DEDICATED GRAY WATER SYSTEM _ iI I I __ _ M � 11 _ (� I{ A _ I
DEDICATED WATER RECYCLE SYSTEM _, III _ H. J I M I 1� II I 1I
DISHWASHER II p '11 I 1 h d f
DRINKING FOUNTAIN __-- II _ M _I -0-,,,__If, I- ,� I ,
FOOD DISPOSER i 1I Al II� I1 I_ I -
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FLOOR/AREA DRAIN I I' II „_. _M _--aI __� _x
INTERCEPTOR(INTERIOR) ,. I_� _ I( „( N i I 1 =
KITCHEN SINK I I h I
LAVATORY a. _L „L___ IL, Iv 1 1 1 - 1;,,,..L,.--- '�� IIs.__
ROOF DRAIN M II ay d 1 r 0 ii ps
SHOWER STALL I II p .. 1I II t I --I 4� 1
SERVICE/MOP SINK 1 - _ 1 Il .. 1 dl _- I I .._- II_— I I
TOILET T- _�= i, —
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URINAL
WASHING MACHINE CONNECTION I allennigilla
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WATER HEATER ALL TYPES _ I
FLaWOTEMTUIl.-... __ I I
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a : I _ I .I-- . II
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ppjiINSURANCE COVERAGE:
UUWIiIr'l� i Jth arse policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY ❑ BOND❑
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 ❑ 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. ' " '
PLUMBER'S NAME Frank W.Roderick !LICENSE# 7794 SIGNATURE
MPO. JP I:] CORPORATION O# 1762-C PARTNERSHIP❑# LLC[3#
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL
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