HomeMy WebLinkAboutP-12-667 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
C CITY Yarmouth
M& DATE }�
JOBSffEADDREss�jl PEaiii - 44 7
P OWNER'S NAME ��'.�,�
TYPE OR OWNER ADDRESS: t�_�,� �� TEL
PRINTOCCUPANCY TYPE COMMERCIAL �FAX�
0 EDUCATIONAL 0 RESIDENTIALS `�J
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT.❑
FIXl1TRES 1 PLANS SUBMITTED: YES❑ NO
FLOORS-+
CROSS CONN DENCE —____IIIII __1111111111111111111111111111111111111
_—==
DEDICATED SPECIAL WASTE SYS �_��___ ____
DEDICATED GASIOK/SA SYS ==
DEDICATED GREASE SYSTEM =_Mil___En ___ ____
DEDICATED GRAY WATER SYS _�
DEDICATED WATER REUSE SYS 11111111111111111111111111111111
_ _
DISHWASHER le ___ __ __
DRINKING FOUNTAIN __
FOOD WASTE GRINDER UNIT = ____ _____
FLOOR/AREA DRAIN _
INTERCEPTORINTERK)R MI 11111111111011111111111111111111111011111111111111011111
_____ _
LAVATORY __ _
ROOF DRAIN �����__ al __
SHOWER STALL _�����___— __�
SERVICE/MOP SINK __�_��_ - "�"t7��1]__
TOILET fir' 3\!��' 7n11__
__I_ aire—i 7im11u___
EIIIIIIIII WASHING MACHINE CONNECTION _____ IIrdar [ri SI�,.,__
�a____��iii�r�l■,1__=
_______t♦11 -_1_111 RTM 1___
__________111 r ___
Sagal______ __ __
I have a current I INSURANCE COVERAGE ___� ��_
!)4L rxxe policy or its substantial equivalent whith meetsthe requirements of MGL Ch 142 YESIX1 NO 0
If you have checked Yfg please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee gmasabsti the Insurance
Massachusetts General Las,and that my signature on this permit application mum this coverage by Chapter 142 of the
• SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
I hereby certify that d of the details and Information I have submitted(or entered)
regarding Knowledge
a theothat al plumbing work and Installations performed under the �i°appliptfon are true and accurate to the best ti
Massachusetts State Plumb D s Laws.
aw . this a my
Ing Code and Chapter 142 of the General Laws � ��be ��an Pertinent
NAME: v i •�.P tin a' CENSE I Nle,_ AWL,etb,
COMPANY NAME USi.. Ennam SIGNATURE
ADDRESS: IC ..,Mnrillmniffiwnie
car:E-gi STATE: rail ZIP: wropizas FAX: "—
�• CELL: �—�—��I
: E:=RNEYRUW � L ih7:�1�l3frerarana
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❑ CORPORATION❑4 E=1 PARTNERSHIP❑4
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