HomeMy WebLinkAboutBLDP-21-000099 i1AP; p_KcC�.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
';i1jE CITY South Yarmouth MA DATE 7/1/2020 PERMIT#/ D/"-91fCf6W
JOBSITEADDRESS 90 Quartermaster Rd OWNERS NAME Coelho
POWNER ADDRESS same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED:YES❑ NO
FIXTURES 1 FLOOR—. a5M 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
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
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 RI N0 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE Of COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY(0 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I ant aware that the licensee does not hav@ 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 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application am true and accurate to the best of my knowledge
and that all plumbing work and Installations performed fader the permit Issued for this application will be in cemptance with at Pertinent provision of the
Massachusetts Stele Plumbing Code and Chapter 142 of the General Laws. 1//ea. L 1/ /JRE PLUMBER'S NAME Herbert Healis LICENSE#20177 S Y( fSIGNACATTUURE
MP❑ JP I ] CORPORATION 0# PARTNERSHIP 0# LLC❑#
COMPANY NAME USA Merhaniral ADDRESS 78 Studley Rd
CITY South Yarmouth STATEMa ZIP 02864 TEL 508 776 5495
FAX CELL EMAIL hhealis@vahoo.com
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