HomeMy WebLinkAboutBLDP-17-001965 tzzu 1
; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 9/27/16 PERMIT#e3-0117-0V 61-
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JOBSITE ADDRESS 12 CAVASBACK LANE OWNER'S NAME;DEREK MENANGAS
OWNER ADDRESS SAME _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL �
PRINT
CLEARLY NEW: _. RENOVATION::_ ; REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES-1 FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING EOUNIAIN — -
FOOD DISPOSER
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 PIPING
OTHER (, _"<tO1&J pat'Ct1ry
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 12 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application : :true and .ccurate to e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be ' plian e ,' • 1 inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
a
PLUMBER'S NAME Richard J.Whiteside LICENSE# 15850 SIGNATUR
MP JP CORPORATION '# 3969 PARTNERSHIPS • LLC,.,� #i
COMPANY NAME Murphy Services Inc : ADDRESS 34 Whites Path
CITY: South Yarmouth STATE MA ZIP 02664 TEL`508-760-1660
FAX ' 508 760 1670 I CELL, EMAIL cshea@callmurphys.com // ekarukas@callmurphys.com
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