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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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` a"" • CITY Yamtouthport MA DATE 10122114 PERMIT#t ttJS'12o?ol06
JOBSITE ADDRESS 181 Thacher Shore rd OWNER'S NAME Carol Condon
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL I
PRINT
CLEARLY NEW RENOVATION: REPLACEMENT:✓ PLANS SUBMITTED: YES NO
FIXTURES 1 FLOORS 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/OILJSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1 _
WATER PIPING
OTHER
BACKFLOW PREVENTER 1
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INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of M CIQ13 a$.20 No
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX B LOAT
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LIABILITY INSURANCE POLICY�I OTHER TYPE OF INDEMNITY BOND BY. LDIN_CL1
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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 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.
PLUMBER'S NAME Walter Nye LICENSE# 32083 SIGNATURE
MP JP CORPORATION # PARTNERSHIP # LLC #
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COMPANY NAME Nye Plumbing and heating ADDRESS 1 Canary Ln
CITY West Yarmouth STATE MA ZIP 02673 TEL 508-246-3349
FAX CELL EMAIL
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