HomeMy WebLinkAboutBLDP-19-001976 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
gti -Z CITY:Yarmouth MA DATE 10/3/2018 PERMIT# ` 74°
JOBSITE ADDRESS 1[ 1 Atlantic Ave OWNER'S NAME Grew
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: ' PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR—, 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) li
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER Utility sink 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,144. SI- I NO 4jD
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
OCT 03 2018
LIABILITY INSURANCE POLICY .• OTHER TYPE OF INDEMNITY BOND _.J
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chap 142 of the yT
Massachusetts General Laws,and that my signature on this permit application waives this requirement. GD
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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Peter J.Hassett LICENSE# 11682 SIGNATURE
MP JP CORPORATION • # 3506 PARTNERSHIP# LLC j#
COMPANY NAME Hassett Plumbing and Heating, Inc. I ADDRESS 8 Skipper Lane CITY Yarmouth Port i STATE I MA ZIP 02675 ( TEL 508-744-7555
FAX CELL 508-237-2175 EMAIL
Ipetedhassett@gmail.com @gmail.com
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