HomeMy WebLinkAboutBLDP-19-004055 d t/ /1V#-7f C+rr
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
itYar CITY Yarmouth MA DATE 1/9/19 PERMIT#/
JOBSITE ADDRESS 7 Drake St OWNER'S NAME Cerbone
OWNER ADDRESS c/o Dan Speakman Construction TELL 508 432 5565FAX�
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL -i RESIDENTIAL ,J
PRINT
CLEARLY NEW:ED 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 I _.
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL J
SERVICE/MOP SINK
TOILET j
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 0 NO i
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
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 Stephen D. Ewing LICENSE# 15281 SIGNATURE
MP JP CORPORATION # 3672 PARTNERSHIP®# LLC®#
COMPANY NAME Edgewater_Plumbing&Heating ADDRESS i P.O.Box 656 �--- -- - ---- -
1 t-i - -
CITY Sagamore 1 STATE I MA I ZIP . 02561 1 TEL 508-317-9680 '
FAXI CELL 508-737-0077 1 EMAIL I steve@edgewaterplumbinginc.com 1t
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