HomeMy WebLinkAboutBldp-19-006638 I/1AP /ab P4,(C l6 p3 3
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'" CITY/TOWN YARMOUTH MA DATE 5-16-19 PERMIT# �9L0r
28 CRAB CREEK LN
JOBSITE ADDRESS OWNER'S NAME BROWN
POWNER ADDRESS TEL 413-478-8412 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL in
PRINT
CLEARLY NEW:❑ RENOVATION:I] REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 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/OIL/SAND 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
WATER PIPING
OTHER OUTDOOR SHOWER 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [X 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 corn liance ,:th all j rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i� .
PLUMBERS NAME RONALD CONTE LICENSE# 15696 SIGNATURE
MP IX] JP® CORPORATION M# 4178 PARTNERSHIP❑# LLC❑#
COMPANY NAME SNOWS FUEL CO ADDRESS 18 MAIN ST
CITY ORLEANS STATE MA ZIP 02653 TEL 508-255-1090
FAX CELL EMAIL KEVINASNOWSFUEL.COM
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