HomeMy WebLinkAboutBLDP-17-003543 121'b ec]
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
11 .- CITY YARMOUTH _.__�...i MA DATE 1/4/17 PERMIT# P /7 3.517
JOBSITE ADDRESS L 30 WILD HUNTER ROAD OWNER'S NAME[ BRIAN ROBBINS
P .
OWNER ADDRESS SAME TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL „__I EDUCATIONAL _I RESIDENTIAL f�1
PRINT
CLEARLY NEW: RENOVATION:`I ` REPLACEMENT: PLANS SUBMITTED: YES NO'
FIXTURES-1 FLOOR-4 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 I �,-
DRINKING FOUNTAIN
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
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 f. J ' 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
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicatio e 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 b3.mpl a all-ER,tinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
.40 PLUMBER'S NAME; Richard J.Whiteside LICENSE# 15850 SIGNATURE
_ _ l
MP JP _ CORPORATION"J# 3969 PARTNERSHIP[ l# ILLCI ]#1
COMPANY NAME Murphy Services Inc 1 ADDRESS 34 Whites Path
CITY South Yarmouth STATE I MA ZIP 02664 i TEL 508 760 1660
FAX 508-760-1670 CELL EMAIL cshea@callmurphys.com // ekarukas@callmurphys.com
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