HomeMy WebLinkAboutP-19-4001 ( �* MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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. g ,C CITY YARMOUTH , MA. DATE 1/3/19 PERMIT#/46/4/7110 /
n JOBSITE ADDRESS 745 WILLOW STREET OWNER'S NAME KEATING
r OWNER ADDRESS: SOUTH YARMOUTH TEL: FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXUTRES 1 FLOORS Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND 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/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I _
WATER PIPING
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND ❑
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 applicationaretrue and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applicati will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Vn/•'ClJ� f
PLUMBER NAME: LEON E CLARK,JR. LICENSE If 11734-M SIGNATURE
COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: MA ZIP: 02660 FAX 508-385-9177
TEL 508-385-8868 CELL: 508-367-1452 EMAIL karen@tcplumbing.net
MASTER 0 JOURNEYMAN❑ CORPORATION 0 it PARTNERSHIP❑it tic❑#
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