HomeMy WebLinkAboutBLDP-17-003393 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY S Yarmouth _ MA DATE 10/21/16 PERMIT# /P P.—/7--off'
JOBSITE ADDRESS 31 Melville Road OWNER'S NAME Ralph Dimonte
POWNER ADDRESS Same TEL IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW: .I RENOVATION:LI REPLACEMENT: 'I PLANS SUBMITTED: YES T NO(1
FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB -- A i �€ '
IA CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM ,
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM ffIIIIIIIIIIIIII 1 IIIIEMIII
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I ii 41 1 Z.
KITCHEN SINK
LAVATORY
ROOF DRAIN i
SHOWER STALL i 'I � I I E
SERVICE/MOP SINK E ) .__.
TOILET
URINAL .._ i' 4 —'I ,I
WASHING MACHINE CONNECTION 71-- i 1 1 , 6 'I r
WATER HEATER ALL TYPES
WATER PIPING
1-4 OTHER BACK FLOW 1 1_
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 171 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 Ej 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / n K dJe Q �—
PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 SIGNATURE
MP� JP® CORPORATION El# 1762-C PARTNERSHIP®# I LLC, #
COMPANY NAME Rusty's Inc. ' ADDRESS 222 Mid-Tech Drive
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CITY West Yarmouth 1 STATE MA ', ZIP 02673 . , TEL 508-775-1303
FAX 508-771-9310 1 CELL i EMAIL nick@rustysinc.com
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