HomeMy WebLinkAboutBldp-20-000294 'i-^ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I S= GJ PARCEL MA DATE 7/17/19 I PERMIT# /, --00 4��T
JOBSITE ADDRESS 25 Mitchelles Path West Yarmouth ! OWNER'S NAME William Greene Jr. 1
POWNER ADDRESS same I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL .
PRINT
CLEARLY NEW: RENOVATION: 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 GASJOIUSAND 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 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1 I
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 . NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY . 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 .:�, my k .ge
and that all plumbing work and installations performed under the permit issued for this application will be in compli:•.. >-="'Perti.= pro--ion of ,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Michael Pereira _ _ _ I LICENSE# 10600 _ — SI '•
MP " JP CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME M.D.Pereira PLG.&HTG. I ADDRESS 27 Lawrence Ln. I
CITY centerville I STATE Ma I ZIP 02632 1 TEL 508-790-2686 I
FAX CELL 508-776-5846 I EMAIL usermvp8181@aol.com
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