HomeMy WebLinkAboutPlumbing Permit _'✓i ! r r- i [ /
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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
� CITY YF}J�YYIpU�� MA DATE Z/ / PERMIT#��y �'� 7
JOBSITEADDRESS Z7 EGC3 /-I19�Y)e �0�� OWNER'SNAMF TF �Ai/K1-L�S�
POWNERADDRESS TEL�f(-7�/- /�5�� FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�
PRINT
CLEARLY NEW: ❑ RENOVATION:[� REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
v FIXTURES 7 FLOOR-+ BSM 1 2 3 a 5 6 7 8 9 �0 i1 �2 �3 ia
\ BATHTUB
� CROSS CONNECTION DEVICE
� DEDICATED SPECIAL WASTE SYSTEM `� 4 "�
�� DEDICATEDGAS/OILISANDSYSTEM
� DEDICATED GREASE SYSTEM '-' t `
DEDICATED GR4Y WATER SYSTEM I � �
� DEDICATED WATER RECYCLE SYSTEM I `t�. +t.r� IJ�� '
�+ ' UI$NW,4JIi'tR
� DRINKING FOUNTAIN
FOOD DISPOSER
` FLOOR/AREA DRAW - ,_>.
O INTERCEPTORQNTE IOg� io (" F�_ t -E. ���
KITCHEN SINK ` �" " � �---�n^� -
S LAVATORY �
� ROOF DRAIN � ` ` ` � `k
SHOWER STALL .p ?
� SERVICE I MOP SINK ,��._ =�• '' ;
� TOILET `,,� -- - — �— --�—� �
,N URINAL � ���
` WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
cS fl C� i — �GT
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. vES� NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILIN INSURANCE POLICY � OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSUR4NCE 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 appliwtion waives this requirement.
CHECKONEONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regartling this applicafion are true and accurat o th� est of my knowledge
and that all plumbing work and installations pertormed under the permit issued for this application will belac�rripl� nce with a erti �nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME DOUG LANGTRY LICENSE# 11305 �9 GNA RE
MP� JP❑ CORPOR4TION❑# PARTNERSHIP 0# LLC�# 3081
COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1268 ROUTE 28
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 774-470-1350
FAX 774-470-1351 CELL EMAIL DOUG-AQUA@COMCAST.NET
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