HomeMy WebLinkAboutBLDP-18-001406 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�ki CITY W Yarmouth MA DATE 9/7/17 PERMIT# j,� / '4v yV�
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l JOBSITE ADDRESS a ks-c1 OWNER'S NAME Lois Crocker t
POWNER ADDRESS Same * TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL LI
PRINT
CLEARLY NEW: El RENOVATION:LI REPLACEMENT:E PLANS SUBMITTED: YES NOQ
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB Is °
CROSS CONNECTION DEVICE ... � I I ti _-� 1 I
DEDICATED SPECIAL WASTE SYSTEM [--"®r 't iI i 11
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DEDICATED GAS/OIL/SAND SYSTEMr '
DEDICATED GREASE SYSTEM r----.. t
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER - ._.
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN � l 1 :I um: I -
INTERCEPTOR(INTERIOR) h�]® ���
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KITCHEN SINK ' 7 -w E __�.�in-
LAVATORY
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ROOF DRAIN �( _
SHOWER STALL ice...
SERVICE/MOP SINK
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TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING r _ �.
OTHER BACK FLOW
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO J
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY• OTHER TYPE OF INDEMNITY D BOND LI
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 0 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 rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. yy/4 W.4/( ,^/ 6PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 SIGNATURE
MP El JPD CORPORATION Li# 1762-C `PARTNERSHIPQ# I LLC rj# , . m.--
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303
FAX , 508-771-9310 I CELL EMAIL ssavery@rustysinc.com
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