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gZi. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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' CITY I Yarmouth
I, MA. DATE ///,?3/// PERMIT#1)12-2"1
JOBSITE ADDRESS I 97 F/{z,0, /lam I OWNER'S NAME I ,hhe, ,1/e rac,a — I
POWNERADDRESS:I ITL: IF I
PRER OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ig
CLEARLY NEW`g RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO
FIXUTRES 7 FLOORS B&nt 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE / _— -- —
DEDICATED SPECIAL WASTE SYS I f 1 ra .
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYSTEM NOV Z3 7_011 --/
DEDICATED GRAY WATER SYS _
DEDICATED WATER REUSE SYS
DISHWASHER p�� P'
DRINKING FOUNTAIN "til {.�_.,,,
FOOD WASTE GRINDER UNI `f ( 14
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN -
SHOWER STALL
SERVICE I MOP SINK
TOILET _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES SZ(NO 0
If you have checked YE,please indicate the type of coverage by checking the appropriate box below._
LIABILITY INSURANCE POLICY ►t� OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:lam aware that the licensee does not havq 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 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and acc to to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will com ance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME:I/Sieai:n m Car;de_ I LICENSE#I I I6&D I SIGNATURE� rr
COMPANY NAME: I l&t,;el /)nCBr:da Mon � and II OorAase� /n
' (P t I
iCIT Y:I LU '/r,emou4-h (STATE: Ilya ZIP: I 06t67 3 I FAX: 6o?))-77&-95431
TEL:650V,77ff -4666 ICELL:1150Ss)364-37B4IEMAIL:I ICO1elk/JO ® cei'cAs-t. "6 1
MASTER Er JOURNEYMAN 0 CORPORATION'# MIZE PARTNERSHIP 0#I I LLC❑#
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES —
Yes No
•
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It
PLAN REVIEW NOTES
I