HomeMy WebLinkAboutP-14-136 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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ig- a CITY Yarmouth MA DATE 8126/2013 PERMIT# P4' � ldp
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JOBSITE ADDRESS 933 west yarmouth rd OWNER'S NAME Andrew Philbrook
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:DI REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOOR-. BSM1 2 ' 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB - y - -
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM i
DEDICATED GAS/01USAND SYSTEM _ _ __
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM1
DISHWASHER
- - - - .
DRINKING FOUNTAIN ' 4. -
FOOD DISPOSER
FLOOR/AREA DRAIN I - -
INTERCEPTOR(INTERIOR) j _
KITCHEN SINK
J.
LAVATORY r
- -�- -
ROOF DRAIN
SHOWER STALL '
SERVICE/MOP SINK - -
TOILET
URINAL _ - - _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
- __ - --
WATER PIPING _ -
OTHER j - _
building drain 1
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INSURANCE COVERAGE: .. .
I have a current liability insurance policy a its substantial equivalent which meets the requirements of MGI Ch.141 YES El NO ❑
IF YOU CHECKED YES,PLEASE MOICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑l 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 infmnation I have submitted or entered regarding this apps . c.*.G- ' -and ;. .to to the best of my knowledge
and that all plumbing work and installations performed wider the permit issued for this application wig a( r ''-' all Pertinent provision of the
Massachusetts State Pkinbirg Cale and Chapter 142 of the General Laws. 'AAr
PWMBER'S NAME David DuVerger UCENSE# 18252 �/ /SIGNATURE
MP JP CORPORATION 0# 1PARTNERSHIPO# (LLC❑#
COMPANY NAME David DuVerger ADDRESS 26 Dove Ln. _+
( 2 p r �' _
CITY West Yarmouth STATE Ma ZIP 02673 TEL 508944201�C-.EV E '
FAX CELL EMAIL AUG Q ZO13
Lae BUILDING D TMENT