HomeMy WebLinkAboutP-13-224 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_ CITY I Yarmouth DATE I PERMIT to PIS-a y
JOBSRE ADDRESS 17 7 "4'E a4// I OWNER'S NAME
OWNERADDRESS:I ft9 9 d (La J44:' �,/ia),,� / ITEL:I 'Eve'
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 ZEDUCATI6NAL 0 RESIDENTIAL I-1
CLEARLY NEW:0 RENOVATION:d REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 121/
FIXUTRES 1 FLOORS-. ewe . 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASIOIUSAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER r ': r
DRINKING FOUNTAIN ▪ - -
FOOD WASTE GRINDER UNIT t
FLOORIAREADR/11N 1111' 05 4112
INTERCEPTOR INTERIOR I
I I
KITCHEN SINK
LAVATORY T
ROOF DRAIN ▪ I eye/. I
SHOWER STALL
SERVICE I MOP SINK
/
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER AU.TYPES
WATER PIPING
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the
requirements of MGL Ch 142 YES ClNO 0
If you have checked us please Indicate the type aby checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee dggIngthatlhe insurance coverage required by Chapter 142 of the
Massachusetts General Lan and that my signature on this permit application mins this requirement
• SIGNATUREOFOWNERORAGENT 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 he and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permk Issued for this appltp8 n will
proAslon of the Massachusetts Stats Fluty Code and Chapter 142 of the General Laws 'C/ �compliance with all PertinentPLUMBERNAMEI6.011/To.0-e ILICENSE8 d /SIGNATURE
COMPANY
,,NAME: 1///40//,(/ ltr .g I ADDRESS:I/a 160,Q ey/;� 1
CTne:Ielh heel XML S/� I STATE,I1 LP: riPail 1 FAX I I
TEL: In /fj'fil7ICEU.:I (EMAIL I
MASTER JOURNEYMAN 0 CORPORATION 0 i I I PARTNERSHIP 0 81 I LLC 0 ttI 1
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