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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY Yarmouthm" MA DATE 11/7/18 PERMIT#1JPf?`cV5/a9
JOBSITE ADDRESS [39 Chanel Point Drive OWNER'S NAME Silva
`\ P OWNER ADDRESS 82 Walton Ave, H annis 02601 1 TEL -- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL U]
PRINT
CLEARLY NEW:L RENOVATION:Li REPLACEMENT:Li PLANS SUBMITTED: YES Li NOLA
FIXTURES Z FLOOR—I BSM 1 2 i 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB --�- ..—__� :�,_. � �
I CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM ' �
DEDICATED GREASE SYSTEM rOM 1111M11.11.11110111111
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER t
DRINKING FOUNTAIN m
FOOD DISPOSER
FLOOR/AREA DRAIN '
INTERCEPTOR(INTERIOR) :
KITCHEN SINK IIIIIN1
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LAVATORY
ROOF DRAIN
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SHOWER STALL 1'
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SERVICE I MOP SINK .. .��r �.. ... �� , _ ..-... _ I� ,r�.." ._ _
TOILET 1 •
URINAL �i . .. . a _ . „t.i. _,..
WASHING MACHINE CONNECTION 1 rV _
WATER HEATER ALL TYPES Y !
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WATER PIPING _m 6 1 ( — _ .�_._
OTHER I ' 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY D BOND Lj
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 Lj AGENT Li
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 9.1444Rddeted
PLUMBER'S NAME Frank W. Roderick LICENSE# 7794 J SIGNATURE
MPI✓... JP Li CORPORATION 0# 1762-C PARTNERSHIPEl# .....LLC #
COMPANY NAME Rusty s Inc. j ADDRESS L222, Mid-Tech Drive ��
CITY West Yarmouth STATE MA i ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL mburke rust slnc com .Y
929009 afi--.
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it MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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%:� ' 3 CITY `Yarmouth MA DATE 11/7/18 PERMIT#iIDt1/P'-60,3/s ff
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JOBSITE ADDRESS;39 Chanel Point I OWNER'S NAME . Silva
GOWNER ADDRESS 82 Walton Ave, Hyannis,02601 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I � EDUCATIONAL ', L RESIDENTIAL�Li
PRINT
CLEARLY „
NEW: RENOVATION: x REPLACEMENT:' s PLANS SUBMITTED: YES', NO
APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
. , a_.,. _ , � �,- � a. _
BOOSTER
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CONVERSION BURNER � t
COOK STOVE 1 .,, ,.- .� 4 ' f,..
DIRECT VENT HEATER .,-. ..., €., ., ,44..,. . ,.., s._ .. , w_,..,_ . e ,�.-,„,,,_,
DRYER r., _ f.. . 3
FIREPLACE 'm w._ ,
FRYOLATOR g
FURNACE , f
GENERATOR I
GRILLE R' i1
INFRARED HEATER t-a, .,. m I ,�, ,,,,. ? „� _J,.. _, _f-
LABORATORY COCKS ,j ,,,_. t i t 1, t�
MAKEUP AIR UNIT , „,, . ,� . ' -,,,.,„ ... ,�,.... , --, - ,. ..�.. €_._
OVEN ,-,,,':-,,. ,,,;',, rt!„,, ,
POOL HEATER t - ': :t
ROOM/SPACE HEATER t:' ., _ `�. . . ..�a.._ ` i �.. �. . w ...� .,,i'. I
ROOF TOP UNIT
TEST 1 : K
UNIT HEATER i .° i, L ,i 1 ._ b 11 ... . ,
UNVENTED ROOM HEATER A ;"- 7 / f
WATER HEATER
OTHER �;_..r . ....,,.+. ....._.
0.. j .__ __. __ -
t; r
$-».m m.... (r .. _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES � NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ,..,„/,„f OTHER TYPE 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 w, 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7teia4Recedcl¢
PLUMBER-GASFITTER NAME, Frank Roderick !LICENSE# 7794 SIGNATURE
MP•_'t MGF ,.,„ JP"x,I JGF I LPG' ,CORPORATION � #, 1762-C I PARTNERSHIP '#, LLC "#
COMPANY NAME Rusty's Inc ADDRESS;222 Mid Tech Drive
CITY West Yarmouth I STATE MA ZIP'02673 TEL 508 7751303
FAX 508-771-9310 ' CELL "EMAIL'mburke@rustysinc.com
929009 a fi_.
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