HomeMy WebLinkAboutBLDP-16-005474 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WOES(
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t ~ CITY Yarmouth MA DATE 4-1-2016 PERMIT# / -P/4ry d% f '7y
JOBSITE ADDRESS 20 pequod circle OWNER'S NAME Carol beland
P CANER ADDRESS TEL 603 508 0381 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES 7 - - 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
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1
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
OTHER
I I I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent vihic h meets the require%riff as of MGL Ch.142. YES • NO
F YOU CHECKED YES,PLEASE INDICATE TFE TYPE OF COERAGE BY CHECKING T}E APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND
OAR'S INSURANCE WA1v :I am avnere that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Lams,and that rry signature on this permit application waives this requirement.
CI-ErKONECNLY: ONfrR2 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that at of the details and information I have submi ted or entered regarding this application are true and accurate to the best of my know4edge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wth alLPertinent provision of the
Massachusetts State Plumbing C.rv4+and Chapter 142 of the General Laws.
PLUMBER'S NAME Jacob michaud LICENSE# 16029 SIGNATURE
MP JP CORPORATION # PARTNERSHIP # LLC # /6 027
COMPANY NAME Michaud plumbing and heating ADDRESS 1726 santuit newtown rd
CITY Cotuit STATE Ma ZIP 02635 TEL
FAX CELL 508 367 0166 EMAIL Michaudplumbingandheating@gmail.com j,`
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