HomeMy WebLinkAboutBLDP-18-006788 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY YARMOUTH MA DATE 5/30/18 PERMIT# BLDP 18 006788
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' = JOBSITE ADDRESS 152 ROUTE 6A OWNER'S NAME TAFRA CHARLES
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P OWNER ADDRESS TAFRA PATRICIA 152 ROUTE 6A YARMOUTH PORT, MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESD NO❑
FIXTURFS 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 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
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❑ NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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.
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 ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 36 WASHINGTON AV
CITY WEST YARMOUTH STATE MA ZIP 02673 TEL
FAX CELL 5083674424 EMAIL
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