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c� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• CITY I Yarmouth I. MA DATE I /O /-2 l// PERMIT#P I2 _21
JOBSITE ADDRESS V O b Q A'ley %R rem 2cA NQ46WNER'S NAME I M c n /14.o)
POWNER ADDRESS:I I
(TEL:I IFAX:I
TYPE OR OCCUPANCY TYPE COMMERCIAL Ere EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATIONrREPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 1 FLOORS Brit 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR l
KITCHEN SINK / ,1 ` % ' .
LAVATORY 7 .
ROOF DRAIN
SHOWER STALL o �\
SERVICE/MOP SINK , N
TOILET 1
URINAL `
WASHING MACHINE CONNECTION /� ` �/
�-
WATER HEATER ALL TYPES a. sv ; -
WATER PIPING / /
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES all; 0
II you have checked y_,$F ,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY Ere OTHER TYPE INDEMNITY 0 BOND 0
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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 ❑,
' SIGNATURE OF OWNER OR AGENT
I hereby certify that at 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 insWlations performed under the permit Issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws �r
PLUMBERNAMEI/UR-5(y / 5jvttodsa ILICENSE#F*FKI a ({SI TURF
COMPANY NAME id. SLY,GCbo pc)-eSS,aug _tic IADDRESS:IZ3 r4Ffdpp/4- /?c( I
CRY:I/2,//e 2[44- I STATE I 0(.41 ZIP'. I O / & 2--f I FAX: I I
TEL: 177i-647-3y c Icat I IEMAuI I
MASTERDe JOURNEYMAN 0 CORPORATION eft I/d YJ 'PARTNERSHIP❑#1 I LLc❑#I I
Y ` J
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SALON MAIAMI NV'Id
t 1I11213d $ :333
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