HomeMy WebLinkAboutP-12-341 .' MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Yarmouth
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JOBSffEADDRES3 , MA. DATE B�PERMR/121/3/L_T 0 1 a. C 41 j�p� OWNER'S NAME Iram
r OWNER ADDRESS:
TYPE, R OCCUPANCY TYPE: REPLACEMENT:
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CLEARLY NEW:0 RENOVATION:Ef 0 EDUCATIONAI 0 RESIDENTIAL❑ PLANS SUBMITTED: YES 0 NO 0
FIXUTRE31 FLOORS-0 amt
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CROSS CONN DEVICE _ 13_®
DEDICATED SPECIAL WASTE SYS ___
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DEDICATED SPECIAL ANDSYs Man la_—a___ a�
DEDICATED GREASE SYSTEM =__ _____ ____
DEDICATED GRAY WATER SYS allillaa_______
DEDICATED WATER REUSE SYS =__ _______ ___
DISHWASHER _
DRINKING FOUNTAININIM ___
F�WASTE GRINDER UNR ________�______
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INTERCEPTOR INTERIORFLOOR/AREA DRAIN
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LAVATORY KITCHEN NK ■'�___�� ®__®�
ROOF DRAIN _��_e__ ___
SHOWER STALL _■-®___® S__w__
SERVICE
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WASHING MACHINECONNECiION L NMI====_ ___����
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WATF1i PIPING MIMI
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I have a current Iiability(raurar�oe policy or i� �tlM INSURANCE COVERAGE
B equivalent which meets the requirements of MGL Ch.1 • S 241-1v T 2
you have checked y please indicate the1 EI
type of coverage by checking the appoprlate box below. IllU1G'll()1 �I
LIABILITY INSURANCE POLICY (� OTHER TYPE INDEMNITY ,
OWNER'S INSURANCE WAIVER:I am aware that the licensee ; 0 BO '` III JAN 0 3 2012
Massachusetts General Laws,and that my signature on this permit s w a rInsurance equirement by .pter 142oI G DENA,/
this i
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SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGEENNT 0 /,? �Q
hereby certify that al of the details and Information 1 have submitted(or entered
regarding this applka,..4, e d accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit Issued for this ap. .
.
provision of the Massachusetts State Plumbing Code and Cha ter 142 of the Gen: . a� pliance with all Pertinent
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PLUMBER NAME���l�� daallie / ')Lj
LICENSE if HMIS V
COMPANY NAME: (��Q,�e SIGNATURE
CITY: '1 'i`•'��� zeil ADDRESS: El(. .r��
als STATE a H ZIP: T+7�' -��
TEL r- -‘ ,p - .� CELL: '�-�s�. FAX: w. -.-a S-o .9
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MASTER L� JOURNEYMAN 0 CORPORATION 0# _y Q
PARTNERSHIP 0#[ ' LLC Ey#K
au��'ONNOTE�
Tiee—I aFLOW FOR O"'"�a USE ONLY'
oD INSPECTION N NOTEy� No
- 2 r I . Q ' t 1. 'ER ❑ ❑
FM S----FEE: $ PERMIit��
nl AN gyww NOTES ------------
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