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MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
tf-F ' CITY I Yarmouth I, MA. DATEI 7/30/1 0[ IPERMIT# f I3- O 69
JOBSfTE ADDRESS I l /aiWI.id Thr OWNER'S NAME I m0verss'ky I
P OWNER ADDRESS:I ITEL:16'62/1-CeIrI I
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[—
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:rjr
PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 1 FLOORS-0 en 1 . 2 3 4 ` 5 8 7 8 9 10 11 12 13 14
BATHTUB j -
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASIOIUSAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
- IC
DRINKING FOUNTAIN
F0O0 WASTE GRINDER UNIT �� 4
FLOOR/AREA DRAIN (
KRKITCHLAVAC NK INTERCEPTOR INTERIOR j t � � , �m1ti��,2
ROOF DRAINY I54 .
SHOWER STALL o` /
SSSE�EIMOP SINK / I ��
URINALz_/-1---
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` WASHING MACHINE CONNECTION // 11 I �4 _, /� /(�`
WATER HEATER ALL TYPES �� �_
WATER PIPING
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I have a current liabilityInsuranceINSURANCE COVERAGE
policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES
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If you have checked les please indicate the type of coverage by thedthhg the appropriate box below.
• LIABILITY INSURANCE POLICY 03— Oqp ji TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVIER:I am aware that the licensee dogIngthan the Insurance coverage required by Chapter 142 of the
Massachusetts General Was.and that my signature on this permit application waives this requirement,
• SIGNATURE OF OWNER OR AGENT ONE ONLY: OWNER 0 AGENT 0
I hereby certify that all of the details and Information I have submitted(or entered)regarding this applbatbn are true and accurate to the best of my
Knowledge and that all plumbing work and Installations perfumed under the permit Issued for this application MO be In compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERNAME:I/lit /1/ cAri� dd,�,,,E,,�s�E�11 9/„ ,r j
/}'C ct"”` /1 SIGNATURE
COMPANY NAME I /k? r}3 n i_�O .727/4/ I ADDRESS:12_c,—/Jl//jm.--�I r I
CITY:It, i‘--41 evki nil, ISTATE rue; ZIP: 1 474 ) TI FAx I I
TEL: 17 7 C? rr? I CELL:I77y RPM ,/LAEMAILI
MASTER 0 JOURNEYMAN CORPORATION 0 1 I (PARTNERSHIP 0 0`—�LLC❑#( I734i4
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