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y, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
f! s�� CITY Yarmouth MA DATE 12/13/19 _ _ PERMIT# l�Aln 00`7 5_
$110 JOBSITE ADDRESS 23 Oak Bluff OWNER'S NAME Murphy
POWNER ADDRESS Same _ I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL U RESIDENTIAL 0
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CLEARLY NEW:ID RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 0 NOEI
FIXTURES 7 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB KM 01111 11111 11111. _ NM 11111' ___. 111111,
CROSS CONNECTION DEVICE NM MB all NM NM INN NM NM1111111111 ONE MO 11111111111111111111
DEDICATED SPECIAL WASTE SYSTEM 111.11rnermilleimmiumnriummiumilllitillitillialli
DEDICATED GAS/OIUSAND SYSTEM IIIIIIIIIIIFIIIIIFIIIIIIIIIIIrIIIIIIINIIIIIIFIIIIIIIIIIIFIIIIFIIIIIrIIIIIIIIIIIIMIF
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DEDICATED GY WATER DEDICATED GREASE SYSTEM � �
DEDICATED WATER RECYCLE SSYSTEM I [1
DISHWASHER MN 111111111111
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SHOWER STALL11.1111111111.1111M1111.11.11.1111111111111111111111111111111111.111111111
SERVICE/MOP SINK IM MI MI NI NM OM IMIMIIIIII IM IIIIII IIIIIIIIIIIMIT L .
TOILET '. ' I __
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URINAL MIIW1I�WIIlla 1111•11111111011111101.
WASHING MACHINE CONNECTION 111111 MKIII MINI MIN IMMNON NM MI 1.11 INS MIN MI`
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY D BOND El
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 0 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. n j�4All ted
PLUMBER'S NAME Frank W.Roderick LICENSE# x„7794 1 SIGNATURE
MP El JP 0 CORPORATION 0#41762-C PARTNERSHIP J# —I LLC( #
COMPANY NAME Rusty's, Inc_ 3ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth 1 STATE MA ZIP 102673 TEL 508 775-1303
FAX 508-771-9310 i CELL 1 EMAIL mburke at7rustysinc com .. . ._.. .._ ___..
930101 1.111;
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