HomeMy WebLinkAboutBLDP-16-007151 I- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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'�.����,4 CITY YARMOUTH PORT MA DATE 6/23/16 1 PERMIT# N-4/9"-��—'90 VC/
JOBSITE ADDRESS 92 LOOKOUT ROAD OWNER'S NAME[JACKIE O'NEILL
OWNER ADDRESS SAME TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL P1 EDUCATIONAL Li RESIDENTIAL �I
PRINT
CLEARLY NEW:1 1 RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES J NOD
FIXTURES 7 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 'r
DEDICATED SPECIAL WASTE SYSTEM iT
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM —�
DEDICATED WATER RECYCLE SYSTEM L
DISHWASHER
DRINKING FOUNTAIN { _
FOOD DISPOSER
FLOOR/AREA DRAIN _ (
INTERCEPTOR(INTERIOR) _.
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL ., ; IF
WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES
WATER PIPING 1
OTHER I BACK FLOW PREVENTER 1 t 11-
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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( ] NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LJ OTHER TYPE OF INDEMNITY a BOND 0
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 LJ] AGENT ( I
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicati,. :re 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 , amp aice w h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �A A
PLUMBER'S NAME Richard:.1.Whiteside LICENSE# 158504) t 1•J tp
GE
MPD JPO CORPORATIONO# 3969 PARTNERSHIP' I# LLCLJ#
COMPANY NAME Murphy Services Inc J ADDRESS 34 Whites Path
CITY South Yarmouth STATE MA I ZIP 02664 TEL 508-760-1660
FAX 508-760-1670 CELL EMAIL cshea@callmurphys.com // ekarukas@callmurphys.com
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