HomeMy WebLinkAboutP-14-785 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
w=''
`'ilr= CITY I Yarmouth I, MA. DATE S�o?7//y / IPERMIT# P/1-?is
JOBSITE ADDRESS(V,� ?�, g-di�J i 4A I OWNER'S NAME I 'l4r H OYnmi ver// -I
POWNER ADDRESS:I 4'3 Aeee kwiv tdch reirt mr1 •474 ITEL:j fAX:I —
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[- 1
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:@r PLANS SUBMITTED: YES 0 NO[y
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 1
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK -
TOILET
URINAL
MASHING MACHINE MNNECII N
di/ rcER*ft JV oC C-1-4 Fitt—ins
az
Jo (96 410
-
IN 0. 21114
BUILDING DE vIENT INSURANCE COVERAGE
have a current I b nsurancp policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 310 0
If you have checked Y,please indicate the type of coveragebychecking the appropriate box below.
LIABILITY INSURANCE POLICY L(�ebOTHER TYPE INDEMNITY 0 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.
• SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
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. D -'
PLUMBER NAME I R,q ph Gt)9,v€,1QE-Cyy{ LICENSE#(M9?J9' I ,'/ ` ' - SI RE
COMPANY NAME 1,7 c?Ate .L /69, I ADDRESS:I/f1 /L itt-f`/- Jrz5.2p 1
CITY 161,-„.M O0rf I STATE: frAM ZIP: 10,679 I FAX I I
TEL: IV '2:19k-;YFrv6 1CELL:IS%t SyoxiC4EMAIL:I ni-6-A o79v/fit-r4;e1 en et I
MASTER 1/3---JOURNEYMAN❑ CORPORATION❑#I I PARTNERSHIP❑#I I LLC❑#I I
J-l-