HomeMy WebLinkAboutBLDP-13-236 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
L` c '. 1 CITY I Yarmouth n I. MA, DATE�G7I1/I�PERMITS / --it
14
N it �I JOBSITE ADDRESS I $c3 Q;v r S+ ,OWNER'S NAME Ilfli®r o
nal
1.1.1 ,1 OWNER ADORESS l !TEL- FAX.I
TYPE PR OCCUPANCY TYPE COMMERCIAL 0
PEDUCATIONAL 0 RESIDENTIAL Lt
!albOCLFAKLY NEW:0 RENOVATIONS REPLACEMENT:0
_J rPLANS SUBMITTED YES 0 NO❑
1IXUTRES1 FLOORS-' Bard 1 , 2 3 4 S 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK J
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
-1-heirs.tion- r -f iay,
I have a current liabilityinsurance INSURANCE COVERAGE
policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES.'NO
If you have checked YES please indicate the type of coverage by checkbig the appropriate box below.
LUABIUTY INSURANCE POUCYbEr OTHER TYPE INDEMNITY 0 BOND 0
•
OWNER'S INSURANCE WAIVER:I an aware that the 8censee kola hag the Insurance coverage required by Chapter 142 of the
Massad useta General Laws,and that my signature on this permit application sY42 this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
I hereby certify that al of the details and information I have submitted(or entered)regarding this sppliation are true and accurate to the best of my
Knowledge and that al plumbing work and installations performed under the permit Issued tar this applIatior�4? dance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUME NAME:I II hI,,, 01(-- 'LICENSE 81 f 1630
V SIGNATURE
COMPANY NAMEIra.v,n/YIC(�t, Pun.-v -/Y'. IADDRESS:I Il (13�r<a� R-f1 I
cITY:I Ul. Y� �rn- .r) ISTATE: 11!1 ZIP: I n -7s I FAX I I
TEL: r.._05)-77E--.4.654, I CELL 1364.S79 4 J EMAIL I
MASTER❑ JOURNEYMAN 0 CORPORATION I2f,I Z611C I PARTNERSHIP CIO I LLC❑hT
LOW FOR OFFICE»SE ONLY FINAL INSPEG SON NOTES
o�L,ri��ea�cvF1'PION NOTES
•
Yes No
ItaelCATION SERVES AS THE PERMIT 0 0
FEE: S PERMR t
?LAN REVIEW NOTES