Loading...
HomeMy WebLinkAboutP-12-078 ,. ( 2 07I- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO PLUMBING I=_ et . — . CITY/TOWN:(,,, � , 0._.m _ I APPLICATION DATE r ! _ _ �1— ;-}}�te�nn. //�� ((�� JOB ADDRESS: „ 9. . '' MAW RaezD .. .--P. PLANS SUBMITT•0 YES En No . ig 01,P OCCUPANCY TYPE: COMMERCIALD RESIDENTIAL lig; 0B 201i NEWT ALTERATION REPLACEMENT REMOVALIDEMOLITION© ' EUILDINr.gen. f PLUMBING: PIPING-FIXTURES-FIXED APPLIANCES-APPURTE •'i • ""tiw» ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS ALTERNATIVE TECHNOLOGYDISPOSER SINK: MOPU SERVICE U el ASPIRATOR FI DRINKING FOUNTAIN STERILIZER DRAIN: AREAI FLOOR EJECTOR STORAGE TANK 4 BACKWATER VALVE M EMBALMING I AUTOPSY I I URINAL BAPTISM:FONTIl SACRARIUM I 1 FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM BAR SINK GLASS WASHER WATER CLOSET BATHTUB' WHIRLPOOLI I ICE MAKER j WATER HEATER:ALL TYPES 1. BIDET INTERCEPTOR:ALL INTERIOR WATER PIPING: j CROSS CONNECTION DEVICE KITCHEN SINK r OTHER NOT LISTED 7 DEDICATED: ACID WASTE SYSTEM LAUNDRY CONNECTION DEDICATED: GREASEISYSDT SYSTEM PIPE RORN111111,1 'v `_s �I DEDICATED: GREASE SYSTEM PIPE RELINING WORK ONLY DEDICATED:RECLAIMED WATER ROOF DRAIN DENTAL FIXTURE I EQUIPMENT SINK: 1.2.3 BAY) PREP.f I 1 DISHWASHER SINK:CLINIC Il FLUSH RIM n .... I PLUMBING INSTALLER—FIRM-COMPANY INFORMATION CHECK ONE ONLY fA ua Services 350 Main Street Unit A p Corporation Business#1 1 NAME.L,.q ..._ r __---._ . _I ADDRESS:12...- ,.m __ . . _.,_1 __�»� _ _ — Partnership Business# LWest Yarmouth p CITY: ..._--„.._..»_._. _. —.._.._.&STATE ..IMAZIP 102673 .w.,.. © EjLLC Business#1 3081 I 774-470-1350 [Cioug-aqua@comcast net _ _ _ TEL: �_—__ ._—_». FAX: .- __--,� EMAIL. flDBA/Unincorporated • NAME OF LICENSED PLUMBER: Doug Langtry INSURANCE COVERAGE I have a current liability insurance policy or,its substantial equivalent,which meets the requirements of MGL.Ch.142 YES NO 0 • If you have checked Lei,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 0 Other type of indemnity D Bond El 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': AGENT 0 Signature of Owner orrOOwwner s Agent OWNER'S NAME:LS Voll__.-1t Pe2ioteel.. .. ... ..,1 TEL No 3.tiOZ� O - FAX: . I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. (OFFICE USE ONLY) TYPE OF LICENSE: Permit#r-PI 2- — a • ❑✓ Plumber gn u of rcens Plumber Inspector I I .r r^`} ['Master / License Number: 13— Fee: ['Journeyman S1LON M31A321 NV7d #11WN3d S :331 ❑ 9 11WM3d 3H1 SI/S3A113S NOIiVaIlddV SIRE oN saA SaION NOI1D3dSNI 7VNId KINO 3SR 331930 2104 MO73fl - S3.LON NOI133dSNI ONIUIN[17d 113[1021