HomeMy WebLinkAboutP-12-609 SJ, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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:witr- CITY I Yarmouth I, MA DATE g. —17—/L PERMIT# -P) 2-- tool
JOBSITE ADDRESS Li U S I L UM Le-6-E-%icy I OWNER'S NAME I W e TA V S ell I
P OWNER ADDRESS: 5 M-i t I TEL:( I FAX( I
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Gin
PRINT
CLEARLY NEW:0 RENOVATION:p REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
FIXUTRES T FLOORS Sant 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB —
CROSS CONN DEVICE /
DEDICATED SPECIAL WASTE SYS R E - t.I V e U
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYSTEM •
DEDICATED GRAY WATER SYS , M Y 1N 2OI.
DEDICATED WATER REUSE SYS
DISHWASHERCUILDI ZPARTMENT
DRINKING FOUNTAIN El" 1
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR OvV
KITCHEN SINK
LAVATORY -
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL '
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch 142 YES®NO 0
If you have checked Yf,please indicate the type of coverage by checking the appropriate box below.
LIABIUTY INSURANCE POLICY h OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
• CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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 all plumbing work and installations performed under the permit Issued for this appl will be In compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
4 /PLUMBER NAME I Q,DkV /4tckey IUCENSE# "72,116 i SIGNATURE •
COMPANY NAME I C°Ld'l+/c416v N '-H I ADDRESS:17 his rAirz� J
CITY:[ /4MIWi ci-f'PP 2.T (STATE Ii ZIP: I C.)7 0,410 I FAX
TEL: 15)8-237-L/6(06 I CELL:I I EMAIL: I
MASTER J- JOURNEYMAN 0 CORPORATION❑# PARTNERSHIP 0 9 I I LLC❑#I I
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