HomeMy WebLinkAboutbldp-19-005932 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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=u• � CITY Yarmouth MA DATE 4/12/19 I PERMIT#/ 5'l3
JOBSITE ADDRESS 41 Tanglewood Dr I OWNER'S NAME Kane
POWNER ADDRESS 41 Tanglewood Dr TEL 617-721-9073 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES LI NOD
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE1 I - ,- 11
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM 1 I I, 1 1 II 1 ;
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM I 1 I 1 I I
DEDICATED WATER RECYCLE SYSTEM I II I I 1
DISHWASHER
DRINKING FOUNTAIN p 1 I 1 1
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I
KITCHEN SINK
LAVATORY
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SERVICE/MOP SINK
TOILET MEI 11111111I MINI N ISE NEI MEI MB II MIMI NEI MI MN NMIMN
URINAL 11111
WASHING MACHINE CONNECTION
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OTHER �I, 'MFMJ
III I 1 I
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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 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY Li 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 t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance Wifh)all Pertin t rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c _-7/a—
PLUMBER'S NAME JAMES CARABITSES I LICENSE# 11156 SIGNATURE
MCI JP CORPORATION0# 3759 PARTNERSHIP❑# LLC❑#
COMPANY NAME ARS BOSTON ADDRESS 300 MANLEY STREET
CITY WEST BRIDGEWATER ,STATE MA ZIP 02379 TEL 508-588-9025
FAX 508-558-1059 CELL EMAIL
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ZROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES