HomeMy WebLinkAboutP-12-333 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY I Yarmouth � MA. DATE I 19-I 1 1 !PERMIT#PJ Z'3 3 3
D JOBSITE ADDRESS 14 ('r tunhf n LA. I OWNER'S NAME( R 1 GIG 0151-v 2
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OWNER ADDRESS:) 11 rranbea-t3
i q ITEL•I IFAX:1
TYPE OR OCCUPANCY TYPE COMMERCIAL IDEDUCATIONAL 0 RESIDENTULL%
PRINT
CLEARLY NEW:0 RENOVATION:S REPLACEMENT:0 PUNS SUBMITTED: YES 0 NO❑
FO(UTRES 1 FLOORS-, ears 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/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
Sepitt Rechit e(Ca- - X
INSURANCE COVERAGE
I have a current)lability insurance policy or Its substantial
equivalent whtch meets the requirements of MGL Ch.142 YES WO 0
If you have checked lis,please Indicate the type of coverage by checking the appropriate box below.
UABILRY INSURANCE POLICY ®. OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does nothave the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
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 installation perfumed 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. yx
PLUMBERNAMEI c-wJer) our 1,3c me IUCENSE#1IP(o ito I SIGNATURE
COMPANY NAME: 1 /a+ MOItArnbhn9 fin4 NPOtincj IADDRESS:12U T)aOncI'1lVP t-v1 . I
CITY:l ,Co. Denims J JSTATE I kc-J ZIP: ( D210o0 J FAX I
TEL: f O 7L0 I- ICELL:1 IEMAL:) 1o(+hoart pMtlle tib P oMoofcni
MASTER 0 JOURNEYMAN X. CORPORATION 0# {PARTNERSHIP❑#1 J LLC❑#I
(PW - FINAL INSPEC�'lON NOTES
ROUnINSPEl'I'ION NOTES
BELOW FOR OFFICE USE ONLY
Yes No
THIS AFFIXATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT
PLAN REVIEW NOTES