HomeMy WebLinkAboutBLDP-16-003806 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
' L CITY[Yarmouth MA DATE 12/18/15 PERMIT# //6'OO 3c
JOBSITE ADDRESS 7 Mirror Brook Road West Yarmouth OWNER'S NAME Blake
POWNER ADDRESS Same M#58/P#377 ` TEL FAX '
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:0 �p PLANS SUBMITTED: YES❑ NO0
FIXTURES 7 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE i I ,
DEDICATED SPECIAL WASTE SYSTEM 11 U , - I
DEDICATED l''
DEDICATED GREASIE USAND SYSTEMSTEM j
DEDICATED GRAY WATER SYSTEM 1 I (f i
DEDICATED WATER RECYCLE SYSTEM j , 1 i !
DISHWASHER
I►/.�_ I A\-L:1 ISM V 1 I ♦"SW L.,.. \ -1 +.
DRINKING FOUNTAIN ,
FOOD DISPOSER {
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I
KITCHEN SINK d
LAVATORY ! r I
ROOF DRAIN
SHOWER STALL 11 , U I
SERVICE/MOP SINK '
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TOILET
URINAL I 11 I
WASHING MACHINE CONNECTION 1 i ,
WATER HEATER ALL TYPES 1
WATER PIPING ! I I
OTHER
it L �
? 1 1 I Y t
1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
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 li
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 a cc a f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com nce all Pertinent pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME James Pazakis LICENSE# PL-15030-M SIGNAT E
MP JP El CORPORATION❑# PARTN IP❑# LLC❑#
COMPANY NAME Self ADDRESS 158 Whittier Drive
CITY Dennis STATE MA ZIP 02638 TEL 508-258-0513
FAX CELL EMAIL Halltechnician@comcast.net
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