HomeMy WebLinkAboutBLDP-17-001535 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I
=;,C CITY YARMOUTH MA DATE 9/23/16 PERMIT#&dill 7-0af61r
JOBSITE ADDRESS L208 SOUTH SEA AVENUE ] OWNER'S NAMErLORRAINE O'CONNELL ,
POWNER ADDRESS I SAME ,,.., TEL 508 775 9420 .. . . FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL .e. RESIDENTIAL
PRINT
CLEARLY NEW: ,,j RENOVATION:Li REPLACEMENT:E PLANS SUBMITTED: YES El NOLw,,,
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i if 3 i it ....._ a'
CROSS CONNECTION DEVICE x ` 1'
DEDICATED SPECIAL WASTE SYSTEMr-111-11-1111 ' ' I ', '
DEDICATED GAS/OIL/SAND SYSTEM ; � @I �i€ J ar ir
DEDICATED GREASE SYSTEM i �®
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM f'
DRINKING FOUNTAIN :I '' . ,
INTERCEPTOR O. I ,
KITCHEN SINK i, y '
LAVATORY ;I_
ROOF DR I, i
SHOWER STALL - IIIIMIIIIIIINIIIIIII
i. 4 i
SERVICE/MOP SINK
TOILET
URINAL _:
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER '
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NW 1 iv, ,
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES= i 1 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Li i 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 `v,
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. OL
PLUMBER'S NAME!ED CASWELL — LICENSE# 9119 _ i SIGNATURE
MP w JP jj CORPORATION # 3952PARTNERSHIP # LLC, ,.#
COMPANY NAME CAPE COD GAS HEAT&NC ADDRESS[15 JAN SEBASTIAN DRIVE#D4
CITY1 SANDWICH STATE MA I ZIP 02563 TEL 508 539-9303
FAX 508 833 9389 CELL EMAIL INFO@CAPECODGAS.COM
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