HomeMy WebLinkAboutP-13-147 JVP IZ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY I Yarmouth I, MA. DATE — )2— IPERMIT# --/V7
JOBSITE ADDRESS I ck((c $'r (P IA I OWNER'S NAME I C \-w.A !Z L1c.d Jk' J
POWNER ADDRESSI5AI.//Z E ITEL:I JFAXI
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTW
PRINT
CLEARLY NEW;0 RENOVATION:0 REPLACEMEN'$ PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 1 FLOORS-. Bunt 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GM/OIL/SAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS F A
DEDICATED WATER REUSE SYS , 151(413
DISHWASHER '
DRINKING FOUNTAIN r 1 * 20
FOOD WASTE GRINDER UNIT
FLOOR IAREA DRAIN t
INTERCEPTOR INTERIOR a'
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KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
I have a current liability Insurance policyor Its substantial INSURANCE COVERAGE
equivalent which meets the requirements of MGL Ch 142 YES,�NO 0
If you have checked yj$,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUC'P OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee finalist&the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application Sas 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 application are true and accurate b the best of my
Knowledge and that al plumbing work and installations performed under the perm*Issued for this a=Ir -_. wit ce with ell Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
PLUMBER NAME:f H-4.0 1 V-2✓'ov I LICENSE#1 a Chi Qaj 1 SIGNATURE
COMPANY NAME: I PA./S Yid✓\ v\C / I ADDRESS I -51-0-.4.y L) O L
CITY:I 14.rw Cs-, ISTATE: I Vhcj ZIP: I n-/-G`0---1 FAX: I S E I
TEL: Y?z—953Y I CELL:177 Y-s3r.,g 2IEMAIL:I'{-3fi ,l3- P<<-ms;,j c a o 3 ctat,0, .(
MASTER 0 JOURNEYMAfr CORPORATION❑#I I PARTNERSHIP❑#I I LLC❑#
- ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT
PLAN REVIEW NOTES
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