HomeMy WebLinkAboutBLDP-18-005197 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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-- _-1,l ' CITY Yarmouth ort MA DATE 3/16/18 PERMIT# 0-77_(19 5' <
JOBSITE ADDRESS 40 Old Church St 1 OWNER'S NAME Judy Barnatt
POWNER ADDRESS Same I TEL 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ® RESIDENTIAL 0
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CLEARLY NEW: ® RENOVATION:® REPLACEMENT:El PLANS SUBMITTED: YES® NO
FIXTURES 1 FLOOR-, BSM I 1 2 I 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB J ,' ) 7
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM ) r
DEDICATED GAS/OILISAND SYSTEM >I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DISHWASHER - _ .��. . IL
DEDICATED WATER RECYCLE SYSTEM _.__
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
1
SHOWER STALL
SERVICE/MOP SINK
TOILET i
URINAL _ _ - __ _ __-- — _ _.. _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING Pliiii
OTHER BACK FLOW
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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 0 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ® 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 Q AGENT El
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.
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PLUMBER'S NAME Frank W.Roderick I LICENSE# 7794 SIGNATURE
MP JP® CORPORATION Q# 1762-C PARTNERSHIP®#all LLC❑#
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE UM ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL II EMAIL ssavery@rustysinc.com