HomeMy WebLinkAboutP-12-228 V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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@ CITY I Yarmouth50
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JOBSTEADDRESS 14 1-1 Sox.41, c'#'.4 Ave• I OWNER'S NAME I u/;cv C !Y1 • KAvis
P OWNERADDRESS:I ill SDvt1, SeA �, MA. DATEI Lye. ITEL:I JFAXI II
•
TYPE
PRE POR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL O
CLEARLY NEW:[f RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO p'
FIXUTRES 7 FLOORS-' Bart 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS — i^
DEDICATED GAS/OIL/SAND SYS -
DEDICATED GREASE SYSTEM I---- 1
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS — N E V 0 7 2 fl
DISHWASHER 1 I
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNI
FLOOR I 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
.4cK FLOW cartb'ntkeE. 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142 YES j13-NO 0
If you have checked YES please indicate the type of coverage�/by checking the appropriate box below.
LIABILITY INSURANCE POLICY Lr� OTHER TYPE INDEMNITY 0 BOND 0
•
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 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 installations performed under the permit Issued for this application will bei ••. :', •: , , •- rnent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME I Vi Qp-4.;0 S i WA (LICENSE#13 J 3Ot 5-3 I SIGNATURE
COMPANY NAME I5;144 PLum,LAt¢ I40_41:vb IADDRESS:I155 SAL, Lu 1
CITY:I {-}yAA/Ni5 ISTATE: 414 ZIP: I Oacc,J I FAX: I I
TEL' I(771- Si3 G-011 C I CELL:I I BAA L I I
MASTER 0 JOURNEYMAN❑' CORPORATION 0# PARTNERSHIP 0#1 I LLC t7 s
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 al
FEE: S PERMIT2 ''2E
PLAN REVIEW NOTES