HomeMy WebLinkAboutP-12-207 e ,,;..
t. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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'\J CITY Yarmouth 1, MA DATEI l 0 rT f !PERMIT/01 2----2c.7
JOBSITE ADDRESS I l / IN 0 /1/G✓I S t I oWNER's NAME I van K c n f
POWNER ADDRESS:I )l a- 0""d>7 O sr"
' - ITEL:I (FAXi
TYPE OR OCCUPANCY TYPE / COMMERCIALS EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO
FIXUTRES 1 FLOORS en 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/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN —
SHOWER STALL
SERVICE/MOP SINK R E G E : f D
TOILET
URINAL
WASHING MACHINE CONNECTION OCT2 0
011
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 1211110 0
If you have checked gra please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 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 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 accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit issued for this appilca will be in compliance with all Pertinent
pro'sk o of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAMEIL)as,c_,oc: J /%s�-�� -
q.t r n n �UCENSE#r1a'U.9`/• SIGNATURE
COMPANY NAME 1 C41 I k n G' I ADDRESS: ) I► $a '/d-
CITY:[C r'n J-e v, /le J STATE: [aim ZIP: ( () '4541- J FAX: /
TEL: ITi ' ` d3/.956 . CEU.:I IEMAILI
MASTER 0 JOURNEYMAN CORPORATION 0# PARTNERSHIP 0#I 1 LLC 0#
ROUGH S INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES '
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT
FLAN REVIEW NOTES
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