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HomeMy WebLinkAboutP-13-261 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w ' CRY(Yarmouth , = Ma Mt tan(.40V-2-DATE I >PERMIT# p/:3 o7ro/ JOBSITE ADDRESS I L/f'l/ Gbf c a g- J OWNER'S NAME I M c4L' ., C1-4 I P OWNERADDRESS:I 4)r d Gb/c 9 ITEtQveisat4Fax:Vrp4jry-a -'- TYPE OR OCCUPANCY TYPE: COMMERCIAL 9- EDUCATIONAL RESIDENTIAL 0 PRENT � CLEARLY NEW:0 RENOVATION:0 REPLACEMENTS® ///,1 l2 jai PLANS SUBMITTED: YES 0 NO 0 FIXUTRES 1 FLOORS-. Bari I 2 3 4 5 8 7 8 9 ,18__ __1t._._a2---13--14 BATHTUB . . CROSS CONN DEVICE F' f p- p `' it. i DEDICATED SPECIAL WASTE SYS ! S DEDICATED GAS/OIUSAND SYS !IIL1 2 5 2012 e j DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS ��g/ VO t DEDICATED WATER REUSE SYS ,L ' DISHWASHER — _ �1 DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY 4j ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET H URINAL I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING • I have a current liability Insurance policy or Its substantial INSURANCE COVERAGE equivalent which meets the requirements of MGL Ch.142 YES 0 NO 0 If you have checked yes please Skate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY f"' OTHER TYPE INDEMNITY 0 BOND 0 • OWNER'S INSURANCE WAIVER:I am aware that the licensee floes not havq 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 0 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 aft plumbing work and Installations performed under the permit Issued for this appllca 1• will be In m ? • di all Pertinent provision of the MassachusettsStatePlumbing Code and Chapter 142 of the General Lava PLUMBERNAME:I Ke.� VtLorc ILICENSE#I QWC ,���v/ I tillpPR^TURF COMPANY NAME: I XC:A )kce r c r 9/,5 t-� I ADDRESS:I G.•_G t(c1 ee I CITY:I /4. I STATE: I/1219 LP: I 0/6/ 7 I FAX: I60lrgYt'cPa A I TEL: IFPr$ „t c-9-IQ- ICEW 99F67iod/*€M,vL:I 1Cenec //Pi•(ne- i MASTER EL JOURNEYMAN❑ CORPORATION❑#I I PARTNERSHIP❑#I I LLc❑#I I 6)