HomeMy WebLinkAboutBLDP-19-006137 po 49 9) /V 7,3 y Itakvr
.4., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�_j`� CITY YARMOUTH ! MA DATE 04/24/2019 I PERMIT# /i'--d///�'0�&( >7
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JOBSITE ADDRESS 2 HOOVER RD OWNER'S NAME GOULD I
POWNER ADDRESS 2 HOOVER RD I TEL1 508-685-8138 IFAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL_j EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:Q RENOVATION:J REPLACEMENT:❑ PLANS SUBMITTED: YES LI NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB { II_ I ,J
CROSS CONNECTION DEVICE IL
DEDICATED SPECIAL WASTE SYSTEM 1
DEDICATED GAS/OIL/SAND SYSTEM L J ' I- -
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM :r ,, _ �\ INK
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN r I , i \ IF-7 NM
FOOD DISPOSER ' : I I'—
MI
FLOOR/AREA DRAINMI L i
INTERCEPTOR(INTERIOR)
KITCHEN SINK ®1— mos ' ,
LAVATORY n_I_* I
ROOF DRAIN MI W i` .I-
SHOWER STALL
SERVICE/MOP SINK INN
TOILET 1111
URINAL -1
WASHING MACHINE CONNECTION II _
WATER HEATER ALL TYPES , { -ir---
WATER PIPING r— -11 I
OTHER
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MaNIMICIIIIIIIIIIIIIIII
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i 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 Li
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 Li
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 t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertin t,drovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ✓.,e-i-__
PLUMBER'S NAME JAMES CARABITSES LICENSE#1.11156 _ SIGNATURE
MP Li JP El CORPORATIONO# 3759 PARTNERSHIP❑# LLC❑#
COMPANY NAME ARS BOSTON ADDRESS 300 MANLEY STREET I
CITY'WEST BRIDGEWATER I STATE MA ZIP 02379 TEL 508-18 fl i' E I V E
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FAX 508-558 1059 CELL EMAIL I APR 201y t I
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1_DI G D 8U1EPHRTMENMENT
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
/C/iGi�//i7 471-7 2 ( 3 Yes No
// Ak 6V THIS APPLICATION SERVES AS THE PERMIT El El
FEE: $ PERMIT#
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