HomeMy WebLinkAboutBLDP-17-002825 1.
- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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=4 CITY Yarmouthport MA DATE 11/14/2016 _ ' PERMIT# . 17-Obo25-
JOBSITE ADDRESS 56 Avon Road I OWNER'S NAME John Whitmarsh
POWNER ADDRESS Same , TEL[ JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL(l EDUCATIONAL 0 RESIDENTIAL El
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CLEARLY NEW: El RENOVATION:El REPLACEMENT: v 1 PLANS SUBMITTED: YES 0 NO
FIXTURES 7 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB �� � -�-
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CROSS CONNECTION DEVICE 1 1 A
DEDICATED SPECIAL WASTE SYSTEM I _. -F
DEDICATED GAS/OIUSAND SYSTEM E----1 I v_ 9i
DEDICATED GREASE SYSTEM J ,_ T 7,
DEDICATED GRAY WATER SYSTEM LE' 11� Ir—; `
DEDICATED WATER RECYCLE SYSTEM 1 tl 1 - I
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DISHWASHER .l it ti ',
DRINKING FOUNTAIN 11 11
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I-7I II ....
KITCHEN SINK t ,._... t: ��-_--. . ..
LAVATORY 1 ti
ROOF DRAIN L. .. 1(
SHOWER STALL _ ir i t ,t '' 1
SERVICE/MOP SINK ' -i r----FI _
TOILET II
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URINAL II
WASHING MACHINE CONNECTION 17-7 ' 1 i I-.
WATER HEATER ALL TYPES �� i ,
WATER PIPING - i -
OTHER [BACK FLOW 1 !
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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 J NO f
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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 Ej AGENT ED
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. / �i( ��`,1 �
PLUMBER'S NAME Frank W.Roderick 1 LICENSE# 7794 /�f� SIGNATURE
MP Ell JPED CORPORATION(Q# 1762-C PARTNERSHIP®# LLC # I
COMPANY NAME Rusty's Inc. )ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth j STATE MA l ZIP 02673 I TEL 508-775-1303
FAX 508-771-9310 J CELL I (EMAIL nick@rustysinc.com
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