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Z:, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�1 CITY YARMOUTH • MA DATE 5/6/2013 PERMIT# PIS - -76
JOBSITE ADDRESS 385 WEIR RD. J OWNER'S NAME KIM PIKE
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:ID PLANS SUBMITTED: YES❑ NOD
FIXTURES 7 FLOOR-• BSM 1 • 2 -3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB t
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM1
DEDICATED GREASE SYSTEM 1
DEDICATED GRAY WATER SYSTEMI
DEDICATED WATER RECYCLE SYSTEMI
9 Y - 4
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN - `
INTERCEPTOR(INTERIOR) - _
• KITCHEN SINK -
LAVATORY • —I 1 1 =
ROOF DRAIN ,
SHOWER STALL 1 / I "MEI
SERVICE/MOP SINK 1 i=—
TOILET 1 1 an
URINAL
WASHING MACHINE CONNECTION __
WATER HEATER ALL TYPES. I
WATER PIPING
OTHER * I-
INSURANCE
,a .
COVERAGE:
't I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
\ : IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑+ OTHER TYPE OF INDEMNITY 0 BOND❑
lc)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 ha. . ... ... .. ..ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � —- -
LUMBER'S NAME PETER J.HASSETT (LICENSE# 11682 �(� - S •TURE
MPD PO CORPORATIOND# 3506 PARTNERSHIPQ# LLC0# J
COMPANY NAME HASSETT PLUMBING AND HEATING,INC.I ADDRESS 68 WINTER STREET
M CITY YARMOUTH PORT STATE MA ZIP 02675 I TEL g-744-7555 1 0 M [ r1
,I FAX CELL 508.237-2175 EMAIL hassett357m@msn.com i'l nJ I� I
lr, J� MAY 0 F 01 L}
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