HomeMy WebLinkAboutP-12-418 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
n / CITY I Yarmouth
Ig ,JJ 1, MA DATEI alio n IPERMIT#PI 2_, �{/�
JOBSREADDRESS I'Ig 1124taCA C,/LIP I OWNER'S NAME I i:911. o.- Ice4i i—J '
POWNERADDRESS:I JTELI IFAX:I
TYPREPOR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL 0 .
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO a
FIXUTRES 7 FLOORS-+ an 1 2 3 4 5 6 7 8 9 10 11 12 '13 14
BATHTUB
CROSS CONN DEVICE
-DEDICATED SPECIAL WASTE SYS '
DEDICATED GASIOIUSAND SYS I.
DEDICATED GREASE SYSTEM K C C E V F—D
DEDICATED GRAY WATER SYS
•
DEDICATED WATER REUSE SYS FFR 10 111
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT D i JAS .I�FPF RTME�JT
FLOOR/AREA DRAIN �J�
INTERCEPTOR INTERIOR - n.(G Ir �2 s -V a
KITCHEN SINK I `
LAVATORY I P
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET I Q
URINAL
WASHING MACHINE CONNECTION ' I
WATER HEATER All TYPES
WATER PIPING
INSURANCE
I have a current(lability insurance policy or Its substantial equivalentwhich meets the requirements of MGL Ch.142 YES gj NO 0
If you have checked yu,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY S OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER: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.
' SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT I El
hereby catty that al of the details and intormation 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. '
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PLUMBER NAME:I -11UYN 4-4a(u? IUCENSE# • • bb• �I ��G
SIGNATURE
COMPANY NAME II-1cep e QQV°, ' Her IADDRESS:I6a Mew 'dos c s et I
CRY:I Dtv4A-S ISTATE: t+a/} ZIP: I Or)T,* I FAX I
TEL VcoY)38C-91cr ICELL:h'ak)3L4-4Y&IEMAIL'I to v: kart Ca CeAlttr1 . tier - I
MASTER 0 JOURNEYMAN® CORPORATION 0#[ [PARTNERSHIP 0#1 iLLC❑#
OFFICE USE ONLY .--- .- __FINAL INSPECTION NOTES
Jt0 GH GAS INSPECTION NOTE BFLOW FOR _.._.
di zit/ THIS APPUCAION SERVES AS THE PERMIT '
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yilu /i %, / r 0016' FEE $ PERMIT t C.mea C e N
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1/4/ ... FLAN REVIEW NOTES
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