HomeMy WebLinkAboutBLDP-17-001706 li /1,-n
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY S YARMOUTH MA DATE 09-30-2016n
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PERMIT# / /-1-6t9I76
JOBSITE ADDRESS 129 ELTON RD. OWNER'S NAME1 DANIEL BLAJDA
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� OWNER ADDRESS Same = TEL S:FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW:I... RENOVATION: REPLACEMENT: , PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB .. .
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM r ._ ----- r
DEDICATED GAS/OIL/SAND SYSTEM ,7-- _ .
DEDICATED
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DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 'u ;
DEDICATED WATER RECYCLE SYSTEM ..._ � 11_ 1 J . .
DISHWASHER
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DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN W ...
INTERCEPTOR(INTERIOR) f j,
KITCHEN SINK . ---
LAVATORY i i,
ROOF DRAIN
SHOWER STALL
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SERVICE I MOP SINK -
TOILET rx.�: ...
-URINAL
WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES3
WATER ., ,
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OTHER BACK FLOW 1 ?.. _._
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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 ' 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 i
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 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. 11; hK (,v /4GCA eicIC
PLUMBER'S NAME Frank W.Roderick 'LICENSE# :7794 SIGNATURE
MP JP' CORPORATION',v i# 1762-C :PARTNERSHIP ?#' LLC #
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid Tech Drive
CITY West Yarmouth STATE ` MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 =CELL: =EMAIL ,SELWOOD at�RUSTYSINC.COM
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