HomeMy WebLinkAboutBLDP-19-001374 , r �t
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PE FORM PLUMBING WORK
;-LAW CITY Yarmouth 1 MA DATE 9/5/18 PERMIT#f= /1`C4- /511/
JOBSITE ADDRESS 55 Highland Street OWNER'S NAME
POWNER ADDRESS c/o York Building&Remodeling TEL 774-200-1889 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL El
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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM /r `"`:`�- �
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
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DISHWASHER / , ( r, -''1
DRINKING FOUNTAIN �''`
FOOD DISPOSER 1J4
FLOOR/AREA DRAIN `d
INTERCEPTOR(INTERIOR)
KITCHEN SINK i'
LAVATORY 1' '..'
ROOF DRAIN
SHOWER STALL I-
SERVICE/MOP SINK
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TOILET i .
URINAL
WASHING MACHINE CONNECTION i'
WATER HEATER ALL TYPES ii •
WATER PIPING I
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i 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
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 a Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Stephen D.Ewing . LICENSE# 1 15281 SIGNATURE
MP JP CORPORATION _# 3672 :PARTNERSHIP '#' LLCM#I
COMPANY NAME Edgewater Plumbing&Heating ADDRESS l P.O.Box 656
CITY Sagamore STATE MA ZIP 02561 TEL 508-317-9680 1
FAX CELL 508-737-0077 EMAIL steve@edgewaterplumbinginc.com
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