HomeMy WebLinkAboutP-12-162 IZN MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'"1_ CITY Yarmouth , MA DATE 9/21/11 PERMIT#N2' IG?
JOBSITE ADDRESS 44 Strawberry Ln,Yarmouth Port OWNER'S NAME Paul White
P OWNER ADDRESS: Same TEL:508-362-5096 FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑]
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
FIXUTRES 1 FLOORS esmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
• SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES j
WATER PIPING
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES S NO fl
If you have checked YES,please Indicate the type of coverage by checking the appropriate box below. RECEIVED
LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY ❑ BOND ❑ SEP 2 7i2011
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 1 2•f y#22, bye bcv
Massachusetts General Laws,and that my signature on this permit application waives this requirement fT/� vi
CHECK ONE ONLY: OWNER ❑ AGEATPU
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 be i m ' nce with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME: Ron Conte LICENSE# 15696 SIGNATURE
COMPANY NAME: Ron M Conte Plumbing ADDRESS: 6 Herring Run
CITY: Harwich STATE: 0 ZIP: 02645 FAX:
TEL: 508-237-9714 CELL: EMAIL:
MASTER 0 JOURNEYMAN 0 CORPORATIONS II PARTNERSHIP 0 it LLC 0#