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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY I Yarmouth I MA DATE 1219/14 PERMIT # 1)41'b -60 �3�9
JOBSITE ADDRESS 1100 North Dennis Road, South Yarmouth OWNER'S NAME I Mark White
ADDRESS100 North Dennis Road, South Yarmouth TELI 508-737-661 FAX
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Q
NEW: ❑ RENOVATION: ❑ REPLACEMENT: Q PLANS SUBMITTED: YES ❑ NO❑
FIXTURES 7 FLOOR- BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
_
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
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DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
_
DEDICATED WATER RECYCLE SYSTEM I
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR /A EA PRAIN
INTERCEP I 10
KITCHEN INK
LAVATOR
ROOF O N
SHOWER TA r—
SERVICE I - -- -- �—
__
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] 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 ❑ 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 in complit provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Kevin T Sullivan LICENSE # 13041 SI ATUR
MPO JP❑ - CORPORATION❑# 2433 PARTNERSHIP❑#O LLC ❑#E
COMPANY NAME Ready Rooter, Inc. ADDRESS P.O. Box 371
CITYSandwich STATE F -MA --j ZIP 102563 TEL 508-888-6055
FAX 508.888-0242 CELL p - 070$6 EMAIL Ws@,readyrooter.com