HomeMy WebLinkAboutBLDP-19-000615 i :_ � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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Vt.— CITY iYARMOUTH MA DATE i07/22/2018 1 PERMIT#�i)p/p aa2f5
JOBSITE ADDRESS 106 WIMBLEDON DR OWNER'S NAME BARCE
OWNER ADDRESS SAME TEL[508-725-1955 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ) EDUCATIONAL El RESIDENTIAL I .
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CLEARLY NEW:0 RENOVATION:ED REPLACEMENT:El PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DEDICATED GREASE SYSTEM
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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 EA NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY in OTHER TYPE OF INDEMNITY BOND Li i
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Gen ral Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 1 i AGENT L
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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.N /_
PLUMBER'S NAME LFrank W.Roderick ___J LICENSE# 7794 SIGNATURE
MP EJ, JP L.H CORPORATION # 1762-C ]PARTNERSHIP # LLC0#
COMPANY NAME Rusty's Inc. 1 ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth I STATE MA,. ZIP 02673 j TEL 508-775-1303 Y..i j
FAX F508-771-9310 i CELL" EMAIL 'ssavery rus sinc.com
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