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' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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=. �ip t CITY Yarmouth I MA DATE 111/6/2017 PERMIT#/4 .vvd73/
JOBSITE ADDRESS 151 Winter St. I OWNER'S NAME[David Swanson,William Shaw s
POWNER ADDRESS TEL .FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL ❑ RESIDENTIAL E]
PRINT
CLEARLY NEW:w_r_ RENOVATION:i J REPLACEMENT:LJ PLANS SUBMITTED: YES TI NOTI
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB __,P._.R,,�-_.
CROSS CONNECTION DEVICE —_ �.._ * _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
4
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1
DRINKING FOUNTAIN j
FOOD DISPOSER
FLOOR/AREA DRAIN 4
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
�'LAVATORY 2
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 2
URINAL __. __
WASHING MACHINE CONNECTION 1 _
WATER HEATER ALL TYPES 1
WATER PIPING _
OTHER 1
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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 , NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY< ij 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 n-' 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 t t e best of m knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co : 'n e o' �e • p/.:n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Peter J.Hassett LICENSE# 11682 SIG A RE
MP;.1 JP ID CORPORATION Q# 3506 'PARTNERSHIP❑#F--- ----.--1LLCLJ#
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COMPANY NAME I Hassett Plumbing and Heating,Inc. ADDRESS 8 Skipper Lane
CITY LYarmouth Port STATE MA ZIP 02675 TEL 508-744-7555
FAX CELL 508-237-2175 EMAIL hassett357m@msn.com A
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