HomeMy WebLinkAboutP-19-5869 �`''44 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT 0 PERFORM PLUMBING WORK
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- au CITY(Yarmouth I MA DATE 14/12/2019 PERMIT#/1 00
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t JOBSITE ADDRESS 61 Kate's Path ' OWNER'S NAME Go-tzR
POWNER ADDRESS same j TELI FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Cj EDUCATIONAL [1] R SI'ENTTIAL 12019
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CLEARLY NEW:❑ RENOVATION:n REPLACEMENT:n R ANiiNir t FYN •❑
FIXTURES 1 FLOOR—' BSM 1 2 3 4 5 6 7 8 9 10 11 NOM 14
BATHTUB 111111.1111111
CROSS CONNECTION DEVICE I I EMEEMINIIKII
DEDICATED SPECIAL WASTE SYSTEM ` r 1 1
DEDICATED GAS/OIUSAND SYSTEM
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DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ®®®®I®;®®®,
DRINKING FOUNTAIN Mt M 1 M
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FOOD DISPOSER FLOORIAREADRAIN ® ■
INTERCEPTOR(INTERIOR ®� IMEEME..1111111111M.1111.1111111
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KITCHEN SINK
LAVATORY
ROOF DRAIN 111111111111 INN
SHOWER STALL
SERVICE/MOP SINK 1111 II IIIIIII 11
TOILET
URINAL
WASHING MACHINE CONNECTION 11
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WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E] NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY n 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 c° ian• „■- . •rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C f, 'P O �
PLUMBER'S NAME Charles Stockdale I LICENSE#j 24526 I " SIGNATURE
MP El JP El CORPORATION❑# PARTNERSHIP❑# 1LLCLJ#1 1
COMPANY NAME Charles Stockdale ADDRESS 256 Mayfair Rd.
CITY S.Dennis STATE MA ZIP 02660 TEL 508-398-2843 i
FAX I CELL 1774-208-1613 EMAIL
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