HomeMy WebLinkAboutP-14-799 :3: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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,,, njCITY YARMOUTHPORT— -- MA DATE —84-14 --- PERMIT#_Ph- 7
JOBSITEADDRESS 17OSETUCI�TRL1 OWNER'S NAME llMMELIA
SAME IAIW144BLOCK7
P OWNER ADDRESS _ TFl FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL®
PRINT
CLEARLY NEW.0 RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 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
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN RECEIVED
INTERCEPTOR{INTERIOR} S/�/,
KITCHEN SINK ram-
LAVATORY LIN a 2O 4
ROOF DRAIN
SHOWER STALLtun r)E A MENT
gl1dL 1
SERVICE f MOP SINK sr:__
TOILET � `
URINAL -. _
-
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1 _
WATER PIPING
OTHER BACICROW 1
INSURANCE COVERAGE:
I have a current liability Insurance policy or lb substantial equivalent which meets the requirements of MGL Ch.142: YES Q) NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BYCHECKING THE APPROPRIATE BOX BaOW
UABILff Y INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ ' BOND 0
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
1 hereby certify that al of the details and information I have submitted or entered regarding this application ate true and accurate to ' edge
and that all plumbing wok and installations performed under the permit issued for this application wil be' liance ith all Pe :
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'C
PLUMBER'S NAME UCENSE# 10322 SIG !NT'E
MP® JP 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME WM/CffALKE ADDRESS 6 SASSAFRASS LW
CITY— HARWICHSIAA
TATE — ZIP— 02848 — TEL_--_--_--
FAX_ CELL n' ' eEMAIL_ DF SEASIDE
too 4f(z R( c'IA- 3177 112 EV
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT#
PLAN REVIEW NOTES
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