HomeMy WebLinkAboutBLDP-19-003907 c'u/M/f, /3/_
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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aurrw MAP PARCEL MA DATE 12/28/18 PERMIT# 1 I)/�`/7--L�t11y
JOBSITE ADDRESS 42 Scallop Rd.Yarmouth,Ma. OWNER'S NAME John Spillane
OWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
INTERCEPTORFLOOR AREA DRAIN =-// % 00
(INTERIOR)
6-0
KITCHEN SINK 1
LAVATORY `A).
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1
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 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
hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the •-st of m • edge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance ,ith . e' t pr. ' lo. : the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Michael Pereira LICENSE# 10600 SIG ATURE
MP - JP CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME M.D.Pereira PIg&Htg. ADDRESS 27 Lawrence Ln.
CITY Centerville STATE Ma ZIP 02632 TEL 508-790-2686
FAX CELL 508-776-5846 EMAIL usermvp8181@aol.com
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