HomeMy WebLinkAboutBLDP-18-006239 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
t;w.,ffi$ CITY S Yarmouth MA DATE 5/1/2018 PERMIT# , ,)P/1 O
JOBSITE ADDRESS 24 Studley Rd J OWNER'S NAME Helene Trudeau
POWNER ADDRESS -Same TEL FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL El
PRINT
CLEARLY NEW:El RENOVATION:D REPLACEMENT:0 PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUBI I !I II 1 a r II
CROSS CONNECTION DEVICE a _ ro j
DEDICATED SPECIAL WASTE SYSTEM NM MIK 1111111111 _ i �, ' i 1 .__ -,.. _rt.. 1 I
DEDICATED GAS/OIL/SAND SYSTEM l
DEDICATED GREASE SYSTEM � +
DEDICATED GRAY WATER SYSTEM 1 11
DEDICATED WATER RECYCLE SYSTEM [ -� 1 S ., ,1I 1 !.� I w i I �1 - =_..d.o. 1
DISHWASHER I ;�-'
DRINKING FOUNTAIN ��
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FOOD DISPOSER I I MIMI OM Mill MR an
FLOOR I AREA DRAIN I ..I 1
INTERCEPTOR INTERIOR ] { a. _v1 l 1 1-1
KITCHEN SINK j "; '
LAVATORY __,eallI P 1[ 1 1 . II :_. ... 1 1
ROOF DRAIN l a _I 1 I �_,1 .'..., ( '
SHOWER STALL 1
SERVICE/MOP SINK
TOILET j I I 1
URINAL 8 d
WASHING MACHINE CONNECTION I ( 1 11 I
WATER HEATER ALL TYPES 1
WATER APING 1 I I
OTHER
BACK FLOW { I ,...„:17-11
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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 E OTHER TYPE OF INDEMNITY 0 BOND Ej
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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 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. / n
W.
PLUMBER'S NAME Frank W. Roderick I LICENSE# 7794 tyl/ `C SIGNATURE/
MP El JP® CORPORATION El# 1762-C !PARTNERSHIPE1# LLC®#
COMPANY NAME—Rusty's Inc. 1 ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth J STATE MA ZIP 02673 1 TEL 508-775-1303
FAX 508-771-9310 i CELL 1 EMAIL ssavery@rustysinc.com