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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
wam CITY West Yarmouth MA DATE 07/1012014 PERMIT# P/9---0"0C.
JOBSITE ADDRESS 34 Maine Ave OWNER'S NAME Susan Parigian
OWNER ADDRESS Same
TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
i I i I I I I i i l i l
DISHWASHER I
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN j G
INTERCEPTOR(INTERIOR)
KITCHEN SINK i
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
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OHE' I ' 15K 4 �( L
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By ___ __ INSURANCE COVERAGE:
I have a current abiliV 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 Q OTHER TYPE OF 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 waive*this requirement
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate tot a best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in compile ith all P nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME JASON DREW UCENSE# J-30715 GNATURE
MK: JP❑ CORPORATION❑# PARTNERSHIP❑# LLC D#
COMPANY NAME DREW S PLUMBING ADDRESS 6 AGASSIZ ST
CITY BREWSTER STATE MA ZIP 02631 TEL 508-360-1400
FAX CELL _ EMAIL
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