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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•'_'t CITY I Yarmouth
® ,� (, MA DATEI `r 113 l I {PERMIT 8 P/i —/6Q
U .,co41, I"' JOBSITE ADDRESS 191 1�K 1-I%'A)644 Q.. (Sr C to I OWNER'S NAME I ?E a-hi NO Bw(v
Ph
N. OWNERADDRESSI Saws (TEL:) IFAXI
kt co 1-
1s 1.0._..iTYP_ tilt OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL
M P• I0 RESIDENTIAL Eg
w lc o 'Lice k I YY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
LY • FIXUTRE , FLOORS—. en 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB .I
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASIOIUSAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY t
ROOF DRAIN
SHOWER STALL t
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER ALL TYPES
WATER PIPING
COVERAGE
I have a current(lability Insurance policy or Its substantial lentCwhich meets the
requirements of MGL Ch.142 YES 0 NO 0 1
If you have checked yu,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage
Massachusetts General Laws,and that myby Chapter 142 of the
signature on this permit application waves this requirement I,
• SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
II hereby certify that all of the details and Information 1 have submitted(or entered)regarding file application are true and accurate to the beat of my
awtedge and that all plumbing wait and installations performed under the permit issued for this application will be incompliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME
if 74i./ A
IToY` gotovt,-C IuCENSE#I ao6b9 I / SIGNAIIIRE
COMPANY NAME I H&cri Wol r ()1-1 I ADDRESS:16 a. lv tw 3.50-.% k 1. I
CITY:I vvn:\ I STATE: I w I ZIP: 10 ab 3 f 1 FAX I I
TEL I fro ? r—q"rr (CELL:C oW)361- "OMNL:I tohK.al„t+Q crn...La.\ .A.i l I
MASTER 0 JOURNEYMAN E CORPORATION 0 8I I PARTNERSHIP 0 p I I LLC❑#
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