HomeMy WebLinkAboutBLDP-17 VOID I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�'- CITY W.Yarmouth I MA DATE 11/18/16 PERMIT#01-10P-/7-°e
JOBSITE ADDRESS 7 Holmes Way 1 OWNER'S NAME Angie Voumazos
P OWNER ADDRESS Same TEL FAX 11111.111111
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW:Ej RENOVATION:® REPLACEMENT:Ej PLANS SUBMITTED: YES® NOD
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I l s
CROSS CONNECTION DEVICE � [ � i
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM 11111111111104110.011111.11111111111111001I Com;NM iiiiiiii
DEDICATED GREASE SYSTEM I. 1W IIMOIT_IMIT_
DEDICATED GRAY WATER SYSTEM ;� ��" WOW an mg
DEDICATED WATER RECYCLE SYSTEM it !W 'N Im
DISHWASHER
IJIJHIIRIIII.
4FIERIO
I
SHOWER STALL ,
SERVICE/MOP SINK I,UUI
URINAL iosGa :
WASHING MACHINE CONNECTION i [ 1 r
WATER HEATER ALL TYPES
WATER PIPING
OTHER BACK FLOW .� 11[
II
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ei 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 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 ❑ 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 compliancee with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. F-4,11( 14 nikierle4
PLUMBER'S NAME Frank W.Roderick •LICENSE# 7794 J SIGNATURE
MP El JP CORPORATION❑# 1762-C PARTNERSHIP®# = LLC 0#
COMPANY NAME Rusty's Inc. I ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth I STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL nick@rustysinc.com
Jr ('(
gi5l E)