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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 1/30/17 PERMIT# BLDP-17-003869
-:i JOBSITE ADDRESS 32 IROQUOIS BLVD OWNER'S NAME SMITH TODD M
P OWNER ADDRESS GIADONE-SMITH CHRISTINA E 3 THEODORE DR LEOMINSTER, MA TEL
01453
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL CI
PRINT
CLEARLY NEW: EJ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE NO L]
FIXTURES 4 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 SYSTE
DISHWASHER
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
WATER PIPING
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ElNO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND El
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.
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.
PLUMBER'S NAME David Koss LICENSE#0377 SIGNATURE
MP 0 JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME David J Koss ADDRESS 36 WASHINGTON AVE
CITY W YARMOUTH STATE MA ZIP 026732434 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
DCDMIT
FEES$ PERMIT#
PLAN REVIEW NOTES