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HomeMy WebLinkAboutBLDP-15-000001 I - US 0 Fic w r4; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Vt= . CITY Yarmouth MA DATE 07/0112014 PERMIT# /'/6 00/ JOB SITE ADDRESS 17 Bent Bluff Lane OWNER'S NAME Mary Browne POWNER ADDRESS 17 Bent Bluff Lane TEL 530-913-7437 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0 check# 3423 PRINT CLEARLY NEW: 0 RENOVATION: ®®REPLACEMENT:0 Inspected:0 PLANS SUBMITTED:YES 0 NO El FIXTURES 4 FLOOR 2 ) , u! 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNFCTION DFVICF DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY 1' ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CORNED • 1 WATER EATE ALTYeP4S,,pD OJAHER-PIG�'�/ -1 r`! iO OCHER O \._ 1 IN 01 21114 1 R51DING C: '1 WENT By --- - -" INSURANCE COVERAGE: I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.YES® NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:1 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 application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. yv ,� �/� PLUMBERS NAME Forrest Ferrell LICENSE# M9964 .r/iM,.--—en�`l� SIGNATURE MP ® JP❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME ADDRESS 10 Orchard Way • CITY Sandwich STATE MA ZIP 02563 TEL 508-420-0700 FAx 508-681-0693 CELL 508-420-0700 EMAIL forrest@frogmendivers.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES P(nh Ub ©TL u211 7 ith / Yes No P ft oc GKa- ✓y/Qi/ THIS APPLICATION SERVES AS THE PERMIT Qy 7 FEE: $ PERMIT# PLAN REVIEW NOTES