HomeMy WebLinkAboutBLDP-20-002892 6 A,'7L
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 11/14/19 PERMIT#! D/��4vO� Z
19 AURORA LANE JIM WALSH
JOBSITE ADDRESS OWNER'S NAME
OWNER ADDRESS SAME TEL 508-760-2174 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑■ PLANS SUBMITTED: YES❑ NO❑■
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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
URINAL
WASHING MACHINE CONNECTION
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 III 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 jrue and accurate to th best f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pert nt pr vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME DOUG LANGTRY LICENSE# 11305 711 E
MP❑■ JP❑ CORPORATION El# PARTNERSHIP❑# LLC ■❑# 3081
COMPANY NAME AQUA SERVICES PLUMBING &HEATING ADDRESS 1200 ROUTE 28
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-619-3367
FAX 508-619-3367 CELL EMAIL DOUG-AQUA@COMCAST.NET
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ fz V
FEE: $ PERMIT# !'6/4- // `J/l F
PLAN REVIEW NOTES