HomeMy WebLinkAboutBLDP-17-000423 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY S.YARMOUTH MA DATE:07-20-16 PERMIT# /Y-17 dool
JOBSITE ADDRESS 32 WINDJAMMER LANE OWNER'S NAME EMMA BAKER
OWNER ADDRESS Same TEL 1FAX L.
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:-, REPLACEMENT: PLANS SUBMITTED: YES ,I NO
FIXTURES 1 FLOORS 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 4.
1
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 BACK FLOW
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 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 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 Pe inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a/ 4,20(
PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 SIGNATURE
MP JP CORPORATION j#E 1762-C PARTNERSHIP # LLC W#
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 CELL EMAIL SELWOOD@RUSTYSINC.COM