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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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'1":j1{a CITY West Yarmouth I MA DATE 11/1/2013 PERMIT# r/9 dog
JOBSITE ADDRESS 23 Sioux Road OWNER'S NAME Francis Belo
V\ � OWNER ADDRESS 54 Stonegate Drive E.Bridgewater,MA 02333 ITEL 617-694-8476 FAX
Ne TYPE ORS OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL E]
RINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOD
FIXTURES? FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUBBATHTUB11101, 111 I .i
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CROSS CONNECTION DEVICE I , IS '
DEDICATED SPECIAL WASTE SYSTEM 11 1r1I ,1_i_r
DEDICATED GASIOIUSANDSYSTEM ail000110 , ,0.1 .
- DEDICATED GFtAY WATER SYSTEM Wellini NM i isona a
DEDICATED WATER RECYCLE SYSTEMSilW
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INTERCEPTOR INTERIOR .
KITCHEN SINK
LAVATORY 2- naiP= =0 1.21- 1 11111111n
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SHOWER STALL . Mil -II•t
SERVICE I MOP SINK
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WASHING MACHINE CONNECTION sseseis ..agrEssa
WATER. . -.-Ns''ES _1 arc I_ ni ,i , ,. 4
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L14t � -T INSURANCE COVERAGE:
_uranceor its substantial�eq�uiva . '�i� �1�,i11•�'a
t which meets the requirements of MGL Ch.142. YES❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 co pliance with all Pert' ent ppovlslon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER'S NAME Frank W.Roderick J LICENSE# 7794 �IG ATURE
MPI JP❑ CORPORATION0# 1762-C PARTNERSHIP❑# LLC❑#
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