HomeMy WebLinkAboutBLDP-17-005231 "� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
s "= CITY Yarmouth MA DATE 4/7/2017 PERMIT# 4'aP/7--67 3
L40 JOBSITE ADDRESS 116 Captain Smalls 1 OWNER'S NAME Darlene McCarthy
POWNER ADDRESS Same TEL FAX IIIIIIMM
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(l
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CLEARLY NEW:® RENOVATION:® REPLACEMENT:El PLANS SUBMITTED: YES❑ NOlp
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB MI,Ms Illall ism Iljl 0111111 11111111111111 l,l low 1.1 nog imill
CROSS CONNECTION DEVICE MI low I 11111111mit 1l amoi limi I no limo Iia,ais am
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DEDICATED SPECIAL WASTE SYSTEM 111.11.l.11 miff amis I_j l _ ' l l'
DEDICATED GAS/OIUSAND SYSTEM _
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DEDICATED GREASE SYSTEM hl MI Om a,;�lay 1 M;
DEDICATED GRAY WATER SYSTEM 1111.11111111m Om 11i1- III'I NEMN IIIIII[IIS I ,,I Um
DEDICATED WATER RECYCLE SYSTEM , 11h11 immilim la FINN INS ""Mr_
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DISHWASHER lam INN OmMInu miff gm gin NMI MIK NEI I IIIIII
DRINKING FOUNTAIN MFM.« MlMiINK an NM 11111111 Imo IlolsrseNE am Illoo
FOOD DISPOSER limillim 11,NIBINN Ill1111111111 lam Illlo'I IIIIII I 1111111 11111111111111111
FLOOR/AREA DRAIN I laRliii liali I I I',IN.I l 11111.I_MN_.l MI
INTERCEPTOR(INTERIOR) 111.C imum amimil IOW NM ION MIMI1SIM pm mu um
KITCHEN SINK NMI 111111111111111111111 NMI'S OB.NMI MIS 11111111 11111111 INN INN 11111111/111111111
LAVATORY ,l';I-11 l(li ill liiiii11 low I h I am l!
ROOF DRAIN Nil 1111.111001 l;l 1111 1111111111111 nil NM l;MIK
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SHOWER STALL MN alli,aii II IN,MK I it 111.1 01111i`I lam I I l
SERVICE/MOP SINK 0.1111.10111 I Om Imm,ll,Nowa=1111111• 11111M PIM MN 11111111
TOILET 1111111111115 I hONE MIN poi 1l iiiii,iiiiii II I l aim
URINAL 101111,1111111110111111atiaNimalm aut=l 1,llll:lgni
WASHING MACHINE CONNECTION oat II 11on11111oun INS'IIIIIIII Illi I l Inn'
WATER HEATER ALL TYPES RN,MN INS MN Om IIIIIIII IIIIIII IIIIIII Imo Um INN_ ' NM I IIIIII
WATER PIPING l l 1.1 1111111111111111111111111
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OTHER BACK FLOW 111111111111.INKOINKfIIIIIII'il:lll l/;lpoug l'.
MK N l 1;111'MIK'.INN_a I I I I-l'
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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 El NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LJ OTHER TYPE OF INDEMNITY El BOND El
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 Ej
SIGNATURE OF OWNER OR AGENT El 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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Frank W.Roderick
LICENSE# 7794 SIGNATURE
MP El JP CORPORATION O# 1762-C PARTNERSHIP❑# LLC❑#1111111111111
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth I STATE illerli ZIP 02673 1 TEL 508-775-1303 1
FAX 508-771-9310 CELL IIIIIIIIIIIIIIIIIIIIII EMAIL ssavery@rustysinc.com