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HomeMy WebLinkAboutBLDP-20-002779 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -a."Ickg CITY Yarmouth MA DATE 11/13/19 PERMIT# p 0'©od- er '44, 23 Mayflower Ln Jack McCabe -'I JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS 23 Mayflower Ln TEL FAX L i TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:Eel REPLACEMENT:El PLANS SUBMITTED: YES® NOr;`; FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ___. .i! CROSS CONNECTION DEVICE - DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM — DEDICATED GRAY WATER SYSTEM E DEDICATED WATER RECYCLE SYSTEM _L__ �; — DISHWASHER 1 DRINKING FOUNTAIN _I FOOD DISPOSER j„ _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) 1 KITCHEN SINK T. -1 _ LAVATORY ROOF DRAIN SHOWER STALL V SERVICE/MOP SINK TOILET —. URINAL r` WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _. OTHER 1 r , _� -I.. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES - NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v 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 urate to the best of my owledge and that all plumbing work and installations performed under the permit issued for this application will be' pliance with all Pertinent provision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. <-----. PLUMBERS NAME Virgilio Silva LICENSE# 31395-J SIGNATURE MP'- JP 0 CORPORATION U#IIIIIIIIII PARTNERSHIP LJ# _ _ _ ' LLC LJ# 1 COMPANY NAME Silva Plumbing&Heating ADDRESS 155 Sudbury Lane . > V E LI Hyannis STATE MA ZIP 1I02601 —I TEL I t CITY y L. Ni i t . FAX L J CELL 774-836-0176 EMAIL i virgiliomga@hotmail.com -4e/L C(,C-171-A2-�`1