HomeMy WebLinkAboutBLDP-18-000369 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�� CITY YARMOUTH , MA. DATE 07/13/2017 PERMIT# j,/l J2'-OCC . 'l
JOBSITE ADDRESS 93 BETTY'S PATH OWNER'S NAME SMITH
POWNER ADDRESS: WEST YARMOUTH TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL El EDUCATIONAL El RESIDENTIAL ■❑
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CLEARLY NEW:El RENOVATION: ❑■ REPLACEMENT:El PLANS SUBMITTED: YES El NO El
FIXUTRES 7 FLOORS-I 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/OIUSAND 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 I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER ALL TYPES
WATER PIPING
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES . NO El
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ❑■ OTHER TYPE INDEMNITY El BOND El
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 El 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`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 compliance0m with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f' ��C
PLUMBER NAME: LEON E CLARK,JR. LICENSE# 11734-M SIGNATU
COMPANY NAME: TC TYNDALL&CLARK PLUMBING AND HEATING ADDRESS: 18 ATLANTIC AVENUE
CITY: SOUTH DENNIS STATE: MA ZIP: 02660 FAX: 508-385-9177
TEL: 508-385-8868 CELL: 508-367-1452 EMAIL:
MASTER 0 JOURNEYMAN El CORPORATION❑■ # PARTNERSHIP 0# LLC 0#