HomeMy WebLinkAboutBLDP-17-004965 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�._<' CITY West Yarmouth j MA DATE 03/23/17 1 PERMIT#,FLif P i7-c k�5
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JOBSITE ADDRESS 41 Higgins Crowell Rd. 1 OWNER'S NAME Da I Xavier
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OWNER ADDRESS 41 Higgins Crowell Rd. ___� TELL _ IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: RENOVATION: - REPLACEMENT: PLANS SUBMITTED: YES N0EJ
FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM .
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1 i._ 1: .- l_
DRINKING FOUNTAIN
FOOD DISPOSER 'i
FLOOR/AREA DRAIN l/t"i- w b 3
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1 „, i s :L ._ .- __ILAVATORY 2_j 7r —ter—_ *
ROOF DRAIN
SHOWER STALL 1 J
SERVICE/MOP SINK _
TOILET 2 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER ALL TYPES 1 ..
WATER PIPING 1 _.J � ...
OTHER
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 ' 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 accurateto the best of my kn ledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli with all Pertinent region the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .
PLUMBER'S NAME;Vir,iq lio Silva I LICENSE# 31395-J I S1ErNA URE
MP JP 0 CORPORATION # 'PARTNERSHIPLJ#7 J LLC # _ _` _A
Silva COMPANY NAME Silva Plumbing&Heatins ADDRESS 155 Sudbury Laane
CITY Hyannis _STATE[MA J ZIP 102601 I TEL
FAX CELL 774 836-0176 EMAIL `vi o m a hotmail.com
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