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S. 41
' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
:1'�1 CRY Yarmouth MA.
rN DATEaZZPERMRN Zl DO
- JOBSREADDRESS ( [fiT'
P OWNER ADDRESS i I OWNERSla NAME l�'(TEL:(�'��nW�-
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PEOR OCCUPANCYTYPE COMMERCIAL U-- �.,JFAX�
CLEARLY NEW:�( EDUCATIONAL ❑ RESIDENTIAL❑
1 RENOVATIOtt p REPLACEMENT p
FDMRES Z PLANS SUMMED: YES p NO p
FLOORS•» era
CROSS CONN DEVICE man
DEDICATED SPECULWASTE SYS =___ alinniall _=_
DEDICATED c;AsroiusANosys __ ���_
DEDICATED GREASE SYSTEM __�___
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DEDICATED GRAY WATER SYS ___�___ a_lean all=
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DISHWASHERDEDICATED A�REUSESYS 1.11 _= UM lal
____
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DRINKING FOUNTAIN MUM Main 111.11111...al FOOD WASTE GRINDERUNR _______
FLOOR/AREA DRAIN __—____
INTERCEPTOR INTERIOR _______in__ ___MIIIMINNI al
SERV/C __
lin NOM NMI Mal
LAVATORY MEM lalle NMEINIIIIIIIIIIMI
ROOF DRAIN
Mal lal le.
SHOWER STALL Mall MIMI NMI 11111111a
701LETE/MOP SINK ______
C011amala le_______
WASHING MACHINE CONNECTION w_____MN in_ _____
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—___ INSURANCE
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I have a anent IIa ima►xrce poky or Its wbsgrtyy
uyo�ha�aa,aaradvlass.rla�,c.uratyaa �'"aI"'cwmarmaat,u,e►e ,baMcl Ch.1 R€s ,. , EV E t,
LIABILITY INSURANCE POLICY� r9 the appropriate box
below.OTHER TYPE INDEMNITY p tl MAR 2 0 2012
OWNER'S INSURANCE WAIVER:Iamarrarethat the tkenseedgm the '. e)EPA'1
Massachusetts Galbrel Laws,and that my signature on this permit application this requirement nsurance coverage required by • 'BY 14 fhb EPA r
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
I hereby certify that al of the deeds and InbbmratIon I have submitted(or entered
regarding thfs application K owfed a and die Massachusetts State work and ad permed under the pain Issued Tar this aretrue. : M w %a my
Plumbing Coda and Chapter 142 of the General Lawn 17=4J� weer all Ported
PLUMBER NAME Mi'nai e- • LCENSE:Q�tI �S,/�
COMPANY NAME u . , . ` V • �� / � � �'�'`"�RE
CITY: NY &5I'1 ADDRESS WPNj 0� .r n M
STATE ElEj
TEL fl'I r/ p CELL ZIP meEMAIL
MASTER 0 JOURNEYMAN p CORPORATION p F CPARTNERSHIP 0 0
c= 1LLC pN���
mv�� ixSPEr'^ON NOTES
.W a OCGICE USE ONYX —
_li 1NcumingN NOTF�
- Yes No
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FEE: PERIgi t
fl W RRv1RW NOTES
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