HomeMy WebLinkAboutBldp-17-005587 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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""= CITY Yarmouthport MA DATE 4/21117 PERMIT#/*al./7--a° ' '
i.60 JOBSITE ADDRESS 194 Main St OWNER'S NAME Rick Bettis
POWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:® RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE •
DEDICATED SPECIAL WASTE SYSTEM % !
DEDICATED GAS/OILISAND SYSTEM x-
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
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DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK - --.
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET a
URINAL - — r_ -
WASHING MACHINE CONNECTION 2
WATER HEATER ALL TYPES 1 "' r
WATER PIPING II _-
OTHER BACK FLOW .- r s s
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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 El
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 ❑ 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.
PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 I SIGNATURE
MP:1 JP❑ CORPORATION 0# 1762-C PARTNERSHI PO# LLC❑#
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA I ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL I EMAIL ssavery@rustysinc.com
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