HomeMy WebLinkAboutBLDP-20-004403 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
— CITY Yarmouth MA DATE 2/11/20 PERMIT# P— "CGyya
JOBSITE ADDRESS 17 Captain York Road OWNER'S NAME Nancy England
OWNER ADDRESS r TELL918-809-7918 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: RENOVATION: REPLACEMENT: / PLANS SUBMITTED: YES NO
FIXTURES 7 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 .y,
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER • - t
•lit
yye INSURANCE COVERAGE:
I have a current liability insurance po Icl' y or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO L
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 Q
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 LStephen D. Ewing =LICENSE# 15281 SIGNATURE
MP JP CORPORATION # 3672 ,PARTNERSHIP # LLC #
COMPANY NAME! Edgewater Plumbing&Heating 1 ADDRESS l P.O.Box 656
CITY; Sagamore STATE MA ZIP (02561 TEL 508-317-9680
FAX CELL 508-737-0077 EMAIL steve@edgewaterplumbinginc.com