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HomeMy WebLinkAboutP-12-222 Y/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kilt' CITY YARMOUTH J MA DATE //—a—,/ PERMIT#'P!Z' .72 2. JOBSITE ADDRESS na S p-ht.i3r. L_a nc I OWNER'S NAME L2:a Dvn f, J • /'� _ 1 P OWNER ADDRESS I *re, c_ TELp. S rzz(6iFAX ^\ R+ •3 aYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Q RESIDENTIAL Q ' ` °PRINT I .NS� ALEARL I NEW:121 RENOVATION:Q REPLACEMENT:Q PLANS SUBMITTED: YES Q NOD 4_ -"- URES 1 ••• ® 4 • 7 8 11 ® 14 LL�,/� _._ � i ' • CROSS CONN CTION DEVICE lallialliiiiMiNSIMMUS f —DEDICATEDS` ILL ' - ID` DEDICATED •S/OIL/SAND SYSTEM 4 I ' • r • • 'fl • a1111111a_ -- a,' .___ - •..... ClalaginliallilliallialiMinlinfiannaninial N. KITCHEN SINInninnaialliliiimallIntalittlitS MICIISIMIIIISSISIMIMMENSIMIS SHOWER STALL SERVICE I MOP SINK a URINAL � S ' • • rl _. NIIIIRIIIIIIIUIIWXMIIRMMNLLSUISRIMMUIIIMIIIMPPI OTHER ■� �� ��iwi� its SIMINIMMialligeliale S Miummiiimmaiali --Slatiliaaleillaillia INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY Q BOND Q 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 Q AGENT Q 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 bes f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in corn.'• ce with all Pertine 1f ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` PLUMBER'S NAME KEVIN LAMOUREUX LICENSE# 15383 tr ATURE MPO Pp CORPORATION 0#ings PARTNERSHIP[J# . LLC©# COMPANY NAME LAMOUREUX PLUMBING I ADDRESS 61 JOBYS LANE CITY OSTERVILLE STATE MA ZIP 02655 TEL 508-420-2068 FAX 508-420-7992 CELL 508-292-5085 I EMAIL lamoureuxylumbing@vetizon.net