HomeMy WebLinkAboutBLDP-16-001342 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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N1�. CITY YARMOUTH I, MA. DATE,09/01/2015 PERMIT#t/ P1 O 4/;
JOBSITE ADDRESS I.37 North Dennis Road OWNER'S NAME Manchuk
POWNER ADDRESS:1 South Yarmouth I TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑■
PRINT
CLEARLY NEW: ❑ RENOVATION: El REPLACEMENT: ■❑ PLANS SUBMITTED: YES❑ NO ■❑
FIXUTRES 1 FLOORS—. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS _
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIP dt /,1p..5 k .i'
a4/6 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 have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El 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 El
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 applica will be in compliance wi all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2
PLUMBER NAME: LEON E CLARK,JR. LICENSE# 11734-M SIGNATURE
COMPANY NAME: I TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS I STATE: MA J ZIP: 02660 FAX: 508-385-9177
TEL: 508-385-8868 CELL: 508-367-1452 EMAIL:
MASTER❑Q JOURNEYMAN❑ CORPORATION 0#( (PARTNERSHIP❑#( (LLC❑#I
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