HomeMy WebLinkAboutBLDE-20-002340 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�' _. __ __ $ MA DATE 0/24/19 PERMIT#� �
`. u�'=- CITY Yarmouth 1
JOBSITE ADDRESS 441 Buck Island Rd. G J} OWNER'S NAME Jean Setterlund __1
p441 Buck Island Rd. --------1
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OWNER ADDRESS V�' _ TELL .�,._., FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Fl
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CLEARLY NEW:LI RENOVATION: _I REPLACEMENT: PLANS SUBMITTED: YES i J NO
FIXTURES•1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I. r T ' 1 ,..,_ i -i .ar, i _. iI..._.__-I
CROSS CONNECTION DEVICE �_
DEDICATED SPECIAL WASTE SYSTEM
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DEDICATED GAS/OIL/SAND SYSTEM f ,1111111 r
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM ! _ t - IMr t
DEDICATED WATER RECYCLE SYSTEM r� I _ i
'IMILIM
DISHWASHER n.•, !'.e... . I I ti
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DRINKING FOUNTAIN 9 * _ r ,
FOOD DISPOSER l -- �..,-_ ,.g r i = 3- r1 I , c a
FLOOR/AREA DRAIN 1 - »�
INTERCEPTOR(INTERIOR) C_ I' #'. 1'. '
KITCHEN SINK L z., i _ A�_
LAVATORY i , ,.� q I
ROOF DRAIN E r
SHOWER STALL I I_— .., a, _. .,11,... ,- —. '.: ._ , .;I r— , -
SERVICE/MOP SINK ... 1 : ,u, ._. �,
TOILET
URINAL 1l x -
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WASHING MACHINE CONNECTION 1. „Mg �� f�: 11 ,11
WATER HEATER ALL TYPES i
WATER PIPING 111111111 NMl , a 7
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OTHER UMil#11111ll { 11 1 C1C:� �LC�; 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'' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE OF INDEMNITY 0 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 0 AGENT U
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 accur. - . •- .. . •owledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn•I•. .• "•I all Pertinent provision •• he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f — _ ,!
PLUMBER'S NAME I Vrgilfo SilvaCC C_ CMCCiLICENSE#[395-J ° SIGNATURE
MP 0 JP ni
CORPORATION 0#1 TiPARTNERSHIP El#. I LLC }#I
COMPANY NAME I Silva Plumbing&Heating �� ADDRESS I_155 Sudbury LaneRECEIVED ' 1
CITY Hyannis I
!STATE! MA —i zip 1 02601 "
43
ga@hotmail.comFAX 5 , , eCELL!�74 836 0176 EMAILvirgiliom a
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