HomeMy WebLinkAboutBLDP-17-006207 a col/71i-y'fr .
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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.1= CITY W Yarmouth ? MA DATE 5/23/17 PERMIT# ,P-,7�o(1
50 JOBSITE ADDRESS 50 Crowell Rd f OWNER'S NAME David Kom
POWNER ADDRESS Same I TEL JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EjEDUCATIONAL ® RESIDENTIAL El
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CLEARLY NEW:® RENOVATION:El REPLACEMENT:Ei PLANS SUBMITTED: YES El NO
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE I I ! I 1I .1r '
DEDICATED SPECIAL WASTE SYSTEM Mil 1 1 ill ir 1 I
DEDICATED GREASE SYSTEM ON IO
DEDICATED GRAY WATER SYSTEM [ il
DEDICATED WATER RECYCLE SYSTEMI !I '
ISHWASHER
FOOD DISPOSER
FLOOR/AREA DRAIN UN Imi fm nor Omam am
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INTERCEPTOR INTERIOR II_llmingI_I_II Ii
KITCHEN SINK
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LAVATORY
ROOF DRAIN1111111111._1111110.1111111.1.0111111111111.1111111. -__ 11111111111W.1111.11
SHOWER STALL
SERVICE/MOP SINK _ II= I
TOILET �_ I-_ OMNI Illll1l�'ii01'
URINALi l
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WASHING MACHINE CONNECTION ! I awlair i
WATER HEATER ALL TYPESinitII . iil
WATER PIPING ,
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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 U] NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY ® 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 El AGENT (21
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 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 1 LICENSE# 7794 SIGNATURE
MP El JP EI CORPORATION 0# 1762-C PARTNERSHIP 0#mom LLC®#NIIIIINB
COMPANY NAME Rusty's Inc. 'ADDRESS 222 Mid-Tech Drive I
CITY West Yarmouth 1 STATE MA ZIP 102673 1 TEL l 508-775-1303
FAX 508-771-9310 CELL 1 EMAIL l ssavery@rustysinc.com
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