HomeMy WebLinkAboutP-13-072 11 AASSACHUSETTS-UNIFORM APPLICATIONtFORKPERMITTO PERFORNIPLUMBINGWNORK--
I'?sf 1 CITY Yarmouth MA DATE 07/30/12 PERMIT # P i 3- 0 71
z''" JOBSITE 10 Ocean Spray Lane(West Yarmouth) M#56/P#20 OWNER'S NAME Marino
POWNER ADDRESS SAME TEL 508-7714814 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:[] RENOVATION: 0 REPLACEMENT: ® PLANS SUBMITTED: YES ❑ NO
FIXTURES FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB l •`
-CROSS CONNECTIONDEVICE 0
DEDICATED SPECIAL WAS I E SYSTEM v
DEDICATED GAS/OILISAND SYSTEM
-DIED1CATED-GRUSWISYSTEfilDEDICATED
14
DED CATED WATER RECY YCLE ES1SYSTEM PUG SYSTEMOA
EP
DISHWASHER —j�
DRINKING FOUNTAIN
FOOD DISPOSER ar
FLOOR TAKE-OWN
1INTERCEPTOR—(INTERTOR)
KITCHEN SINK ACCEPTED
LAVATORY 8
ROOF DRAIN —�
'SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE—CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSUHANL LUVbHAt, :
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY ❑ BOND 0
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 0 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME James Pazakis LICENSE#PL-15030-M SIGNATURE
MP ® JP ❑ CORPORATION ®#C-2803 PARTNERSHIP ❑# LLC ❑#
COMPANY NAME:Hall Plumbing&Heating,Inc. ADDRESS:447 Old Chatham Road
CITY:South Dennis STATE:MA ZIP:02660 TEL:508-385-9127
FAX 508-385-6604 CELL EMAIL Halltechnician@comcast.net