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HomeMy WebLinkAboutP-12-593 aZ.' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . n- CITY Yarmouth JOBSfTEADDREss , MA. DATE n'l PEWIT liTh - 9 Mon— OWNER'S NAME rnitia P OWNER ADDRESS -Ye S6'acr �Y TEL - T� R OCCUPANCY TYPE: COMMERCUIL❑ C�FAX� l CLEARLY EDUCATIONAL (] RESIDENTIAL(� p NEW ❑ RENOVATION:0- REPLACEMENT:❑ /1 Fagg 1 PIANS SUBMITTED: YES 0 NO ID �6 FLOORS an 1 2 3 4 5 11:111 7 aa 9 10 11 12 CROSS CONN DEVICE __________ _ Q DEDICATED SPECW.WASTE SYS _______ DEDICATED GEASIUSANDsrs an IS �_G,�_ DEDICATED GREASESYSTEM _ ��Latalaw i.._ DEDICATED GRAY WATER SYSMal_�_�M_=__Ia__ pi DEDICATED WATER REUSE SYS _ __�� ! 1�1■._ DISHWASHER 11��,%��rl■._ ()FUNNING FOUNTAIN _ ___ __akirw ,,,,IT, T l;._ J F000 WASTE GRINDER 0N11 ���_ �ildLl_m m= t FLOOR/ASTEGRIND �� ______fl -- a rwRCEAREADRAINIOR ___�_IS ___'ViSstti= Vl LAVATORY 7______ �MINIM W����=_ ROOF DRAIN _______ k SHOWER STALL MS lel __�_____®__Eli _ SERVICE/MOP SINK Irsr'__ S__=__ _ IIIIII MI TOILET ______ MIN WASMACHINE CONNECTION _�___MNSal ___ - �����___ IS ____ IIIIII WATER PIPING lel NISEI Sla MN IMO -t-._ emommomm,m...____1111aainollill MN IIIIIIIIINSINIIISMINS • Ihave acurrent Ijq �� arib --C--______�� NPlass Irpolicy the substantial aSi which meets dN b of MGL Ch.142 YES 2,NO 0 you have checked type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 6] OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I an aware that the licensee&Isom thecoveragethiserired by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application sh t. • SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT I hereby certify that a1 of the details and Information I have submitted(or entered) regarding this Know edge t of and that all plumbing work and bahallatian permed under the permit application am�s b withto the beet t of my Massachusetts State Plumbing Code and Chapter 142 of the General Laws. compliance all Pertinent PLUMBER NAME Q �' - • LICENSE if MCI COMPANY NAME ��— SIGNATURE ==l ADDRESS: SOk. /S71 ArTnime cm: STATE: ,J J EP; 02 S TEL .•- FAX Sob-Y 2-'/ ,r C7-ma! CELL: 34.7 o21 EMAIL MASTERg, JOURNEYMAN❑ CORPORATION❑S anal PARTNERSHIP 0 e ©ucpnE=1 e I TIMNMX2KR J—± ---•imnd —S 33J =-__S-----j_______-' ---- rm 0 :::: 9 O Y