HomeMy WebLinkAboutBLDP-15-000457 rte; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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• it* CITY YARMOUTHPORT MA DATE 08/08/2014 PERMIT#1% 216'-ua 4146.
` a JOBSITE ADDRESS 115 Merchant Ave OWNER'S NAME Cheryl Bumham lin
N P tti OWNER ADDRESS Same TEL FAX
t TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIALC]
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOQ
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
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CROSS CONNECTION DEVICE I I I I I-V, ' r
DEDICATED SPECIAL WASTE SYSTEM I _ 1 11 i il
DEDICATED GAS/OIUSAND SYSTEM I I I
DEDICATED GREASE SYSTEM r I
DEDICATED GRAY WATER SYSTEM I ,
DEDICATED WATER RECYCLE SYSTEM ,i i
DISHWASHER
DRINKING FOUNTAIN I I
FOOD DISPOSER 1 i II i
FLOOR I AREA DRAIN i
INTERCEPTOR(INTERIOR) I 1 I
KITCHEN SINK
LAVATORY 11111111
11111
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET �I I ir 7 [-
URINAL I i 1
WASHING MACHINE CONNECTION ,
WATER HEATER ALL TYPES
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BUILDING DEPARTMENT INSURANCE COVERAGE:
I t ave a current liabi'1 r .r policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES C] NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 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 caypliance with all Pert' provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _YY, [/ u'2 / ,C�C
PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 � SIG TUREE /��A
MPC] JP❑ CORPORATION C]# 1762-C PARTNERSHIP❑# LLC❑#
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA ZIP 02673 TEL 50&775-1303
FAX 508-771-9310 CELL EMAIL