HomeMy WebLinkAboutBLDP-17-006458 IMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY South Yarmouth MA DATE 6/7/17 PERMIT# /i-AP )7-0o 1/6-r
12 Dayton RoadKyle Hein
JOBSITE ADDRESS Y OWNERS NAME
OWNER ADDRESS Same TEL 774-313-7078 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 1l
PRINT
CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:❑/ PLANS SUBMI I I Li): YES❑ NO"
FIXTURES 1. FLOOR-* BSM 1 2 3 4 i 5 fi 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASJOIUSAND SYSTEM
DEDICATED GREASE SYSTEM --- -�
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER I _
FLOOR!AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY "UN
ROOF DRAIN
SHOWER STALL r
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEA 1 ER ALL TYPES I
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 YNO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TIE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V 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 instafations performed under the permit issued for this application will be in c pliance with all Pertinent provisionof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME GYQi d._J15hop. LICENSE# 5101 SIGNATURE
MP L� JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME I '"tQh c ie YV.,L1 ADDRESS %3-15 i&€. L�G
CITY 5cur tiiAptrt'1 STATE Ftfi ZIP Or :;c43 TEL L J23 BCa5` t1S
FAX CELL EMAIL YViOI(C.J(ahiCh-Q� 1('1efc(.(/IC•COrV1
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