HomeMy WebLinkAboutBLDP-17-000093 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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` CITY[Yarmouth _I MA DATE 7/11/16 I PERMIT# P-J7 Y x : 113
JOBSITE ADDRESS 36 Russells XI( L�N1i I OWNER'S NAME RichardRussell
OWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL L j EDUCATIONAL " RESIDENTIAL Q
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 7 NoEj
FIXTURES 1 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)
KITCHEN SINK 1
LAVATORY 1
ROOF DRAIN
SHOWER STALL 1 _
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
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 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 I
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 Richard Farrenkopf I LICENSE# 33051 SIGNATURE
MPS JP2j CORPORATION Q# PARTNERSHIP #r 1LLCLJ#1 1
COMPANY NAME R Farrenkopf Ill Plumbing and Heating ADDRESS 20 Haywood Ave + "
CITY South Yarmouth _I STATE MA I ZIP 02664 —1 TEL[5083603175'� —11
FAX JUL 1. 1 2016 9
CELL EMAIL richardfarrenkopf@yahoo.com
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