HomeMy WebLinkAboutBLDP-15-000274 ...' •
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SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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__maul=yt CITY Yarmouth + MA DATE 7/3014 !PERMIT# 'f/02-,5 -OG1at7h/
JOBSITEADDRESS 25 Harbor Road OWNER'S NAME Moylan
P OWNER ADDRESS W. yarn ouch ( TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL*
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:: - PLANS SUBMITTED: YES El NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB L r ._ r,-II j1� r 71- -If w SI 1 _ , f 1 f . ill
CROSS CONNECTION DEVICE , , - _ _ -
DEDICATED SPECIAL WASTE SYSTEM I _ _ I , —11-. -_ ,- 'I u l _ ii . II_:_. s ''1_, .,.
DEDICATED GASIOIUSAND SYSTEM r I l; I I 1 _ _
DEDICATED GREASESYSTEM
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DEDICATED GRAY WATERTERSYSTEM ' Ir Ir �i -- r - -
_ I I I ill- i ;
DEDICATED WATER RECYCLE SYSTEM — F — ,i r
DISNWNSHER :.
DRINKING FOUNTAIN 1, i I
FOOD DISPOSER I 1 i
FLOOR IAREA DRAIN Y 1 n l
INTERCEPTOR(INTERIOR) it , J, I II i 1 I
KITCHEN SINK
LAVATORY [ ,
ROOF DRAIN {
SHOWER STALL ;
I
SERVICE/MOP SINK it 1
TOILET , r
URINAL 1
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MTNIeAZRhLr eE37. U j- r I
NAT L� s1- ak' Pilit _lal
i 29 %ILDING fh r 1'IIiIRi
by--=V f - INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142. YESXI NO ❑
IF YOU CHECKED YES,PLEASE INDICATE
EE---TTTTHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCr/pl OTHER TYPE OF 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 ❑ AGENT ❑
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 cpl®iance witthh a, -Pllrtinent p vision ofthe
Massachusetts State PlumbingnCode and Chapter 142 of the General Laws. aGar �C /..e.,g? f
PLUMBERS NAME ( 'a? (. Si 'I 1-Ae 1 1 (LICENSE# SIGNATURE
MP 21‘ JP El CORPORATI,,ONEI# PARTNERSHIP❑# LLC❑# -
COMPANY NAME 00(lA c-, R1PrtD11 eca1�3IADDRESS nig- NC Ifl ST1212R + I
CITY cb-te-1 1,c1 `1_p STATE MEI ZIP Q 1(p 5 CI TEL sriA -L-las- -(03(as I
FAX CELL S EMAIL
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