HomeMy WebLinkAboutP-12-679 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r
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�- CITY Yarmouth
I. MA. DATEI t,I-1 Cs-2o12 IPERMR>l L2-l��q
JOBSIrEADDRESS I a 41 514{itIA. 141)c I OWNER'S NAME I fl r I^1AInci.u?IA I
P OWNER ADDRESS:I (641AAC ITEL:I IFAX:—
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:E2/ _
PLANS SUSMi77Ep: YES 0 NO❑
FIXUTRES 1 FLOORS-. Bari - 1 2 3 4 5 B 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OfJSANO SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS R C C '
DEDICATED WATER REUSE SYS "
DISHWASHER
DRINKING FOUNTAIN , ;
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN :. ....- ;� _. ..
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY O KI________
ROOF DRAIN •i
wry SHOWER STALL f I —
SERVICE/MOP SINK
TOILET
URINAL •
WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES t
WATER PIPING
INSURANCE COVERAGE
I have a current(lability insurance I or Its
policy equivalent which meets the requirements of MGL Ch 142 YES Q NO 0
If you have checked ns please indicate the type of coverage by oheddny the apprcpriate box below.
LIABILITY INSURANCE POLICY 0 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 ski this requirement
• SIGNATUREOFOWNERORAGENT CHECK ONE ONLY: OWNER 0 AGENT 0
I hereby certify that al of the details and Nformadon I have submitted(or entered)regarding thls applkatfon are true and accurate to the best of
my
Knowledge and that all plumbing work and Installations performed under the permit Issued far this appllgtlon vrill be in..As. 5 th all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER NAME:IMICkgc( 32oLIKSOK ,LICENSE/ IO ,aa /4 " • �a.-..... IM n vTIRE LURE
COMPANII NAME: I I ADDRESS:) 7 Y I<a.k414eti -)r.
CITY:( PtrtpkLin STATE: ✓vta ZIP: I b49(,0 j FAX: I
TEL: IJcat 2241 1LaIl ICELL:I IEMAIL I l4WJ+rPlmer an(Q i rl'dit4
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MASTER JOURNEYMAN❑ CORPORATION❑#I I PARTNERSHIP 0 p I I ILC 0 I I