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I SS, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
a"� CITY yamiouth MA DATE 8126/2013 PERMIT# /y 1�
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JOBSITE ADDRESS 935 west yarmouth rd OWNER'S NAME Andrew Philbrook
P OWNER ADDRESS TEL , IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 1E1
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO0
FIXTURES 1 FLOOR-. BSM 1 2 34 5 6 7 8 1 9 10 11 12 13 14
BATHTUB ti I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM —� z '7-
DEDICATED GAS/OILISAND SYSTEM — _�
DEDICATED GREASE SYSTEM ti
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM t
DISHWASHER �_` _
DRINKING FOUNTAIN a— _
FOOD DISPOSER _� 1/4__
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
-
KITCHEN SINK 1
LAVATORY
ROOF DRAIN
SHOWER STALL \
SERVICE I MOP SINK
TOILET
URINAL r - - _ -
WASHING MACHINE CONNECTION r ' -
WATER HEATER ALL TYPES
-
WATER PIPING , -
OTHER r , , ,r
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑+ 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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the detais and information I have submitted or entered regarding this app. : : and acchrat: .the best of my knowledge
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and that all plumbing work and irstallatims performed under the permit issued fa this application wit be 4. l j: . . a I •ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'jb /
PLUMBER'S NAME David DuVerger LICENSE# 18252 / ,
SIG
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MP El JP +❑ CORPORATION❑# PARTNERSHIP 0# lc 0#
COMPANY NAME David DuVerger ADDRESS 26 Dove In.
CITY West Yarmouth 1 STATE Ma ZIP 02673 TEL 5089442a E G E I V E DJ
FAX CELL EMAIL I Q 201W'j' I
LR B . DEPARTMENT AIL IN EPARTMT
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