HomeMy WebLinkAboutBLD-20-001420 F MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_kl` � CITY Yarmouth MA DATE 09/12/2019 PERMIT#�fL.9/42i. -��y.�
JOBSITE ADDRESS 58 Adams Rd ( OWNER'S NAME Rene Bettey
POWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL Q
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CLEARLY NEW:Q RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES❑ NO(J
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 j 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
I DEDICATED GRAY WATER SYSTEM INK 11111111 INN nal 11111111.111 NM 1n. IIIIII IIIIIII`
IIIIIIIIIMIIIIIIMIIIIIIIHIIIIII'-
DEDICATED WATER RECYCLE SYSTEM MIEN I I - Ile
DISHWASHER ills'O NM NMI MI all 1.115 M IIIIIII allNMMIIIIMMIIII
DRINKING FOUNTAIN 'i I
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FOOD DISPOSER [ Oaf
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INTERCEPTOR PTOR INTERIOR ,f1t�� _ _ mi.,
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KITCHEN SINK i
LAVATORY i
ROOF DRAIN MM M. ' .,
SHOWER STALL N:�'I� [ own.um M�
SERVICE/MOP SINK Ig gm MI'i.- _ WI 1 Ii
TOILET
URINAL I 6. ._ I.. -.
WASHING MACHINE CONNECTION t � 1
WATER HEATER ALL TYPES ` ,
WATER PIPING € ;._ € . _ ,
OTHER I
backflow for boiler
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INSURANCE COVERAGE: f-•, -"'-" --- 1,
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL bR4E 1Q .it101, .
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW i � I
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LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY Li y t
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requiredl by �pt10142 of h r NI r N I
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER [ AGENT L
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 ' Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME JASON DREW —I LICENSE# J-30715 i NATURE
MPLJ JP 0 CORPORATION[# 'PARTNERSHIP # LLC #___I
COMPANY NAME DREWS PLUMBING ADDRESS 6 AGASSIZ ST f
CITY[BREWSTER STATE MA' ZIP [02631 TEL 508-360-1400
FAX 1 CELL EMAIL
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