HomeMy WebLinkAboutBLDP-17-005793 .iL... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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=_ — CITY Yarmouth MA DATE 4 26 17 PERMIT#f31/2P 17—GO j y�f
JOBSITE ADDRESS 8 Maths Drive OWNER'S NAME Eric and Regina Bruno
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OWNER ADDRESS 8 Mattis Drive TEL 774 249 0063 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 1 EDUCATIONAL RESIDENTIAL
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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 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01USAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL {
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
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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 L 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 David Simmons LICENSE# 16259 SIGNATURE
MP i JP Li CORPORATION # i PARTNERSHIP # LLC #13975
COMPANY NAME Devlin Simmons LLC ADDRESS 4 Jeannes Way
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CITY Forestdale STATE MA ZIP 02644 TEL 774-521-3704
FAX I CELL 508-648-2080 EMAIL DevlinSimmonsLLC@gmail.com _,
MAY 03 2011 -