HomeMy WebLinkAboutBLDP-18-003280 piti RC--Lib-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
= 13 CITY Yarmouth MA DATE 11/28/2017 PERMIT# ad.tnV
JOBSITE ADDRESS 44 Green Way OWNER'S NAME Burnett
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK 2
LAVATORY _ 2 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 2 1
URINAL
WASHING MACHINE CONNECTION i
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 ❑x 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 ' - Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Tygue Reed LICENSE#15200 SIG 'TURE
MP{] JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑x # 4047C
COMPANY NAME Coastal Plumbing,Heating and Cooling ADDRESS 299 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-737-8747
FAX CELL 508-246-9959 EMAIL tygue@coastalph.com
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