HomeMy WebLinkAboutP-14-844 ? �Y— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
LW, CITY YARMOUTH , MA. DATE 06/20114 PERMIT# Plq 91-11
JOBSITE ADDRESS 100 LOOKOUT ROAD OWNER'S NAME CIPOLLA
P OWNER ADDRESS: YARMOUTHPORT TEL FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL•
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO t
FIXUTRES 1 FLOORS emit 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 7
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK 1 _ _ -
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL '
WASHING MACHI • TION
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�3UILDINGDf MIENT INSURANCE COVERAGE
I have a rare t .•if.t 's .• 'ce 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.
LIABIUTY INSURANCE POLICY El OTHER TYPE INDEMNITY 0 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 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.
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PLUMBER NAME: LEON E CLARK,JR. LICENSE It 11734-M SIGIGATtJRE
COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: MA ZIP: 02660 j FAX 508-385-9177 •
TEL 508.385-8868 CELL 508-367-1451 EMAIL
MASTER 0 JOURNEYMAN❑ CORPORATION El# PARTNERSHIP 0# J LLC❑#