HomeMy WebLinkAboutBLDP-19-001318 I
• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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% k1_Yt CITY Yarmouth MA DATE 8/28/2018 PERMIT#&nr R'VJJ/7
JOBSITE ADDRESS 23 Lewis Bay Blvd OWNER'S NAME Brian Gallagher
P OWNER ADDRESS TEL 508-330-2872 FAX
TYPE ORI OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL D
PRINT
- CLEARLY/ NEW:1:1RENOVATION:❑ REPLACEMENT:9 PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB -I i J ' I I1
CROSS CONNECTION DEVICE 1 I N 1 ,
DEDICATED SPECIAL WASTE SYSTEM _ 1 _ 1 t _ 1�_ ' I ,
DEDICATED GAS/OIUSAND SYSTEM - 1 IA _ I N I
DEDICATED GREASE SYSTEM I _
DEDICATED GRAY WATER SYSTEM _f k
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER /
DRINKING FOUNTAIN I wit
FOOD DISPOSER I 1
FLOOR/AREA DRAIN 1
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INTERCEPTOR(INTERIOR) 1 1 11 I i it ;
KITCHEN SINK ,
LAVATORY - f - II I I II ( I
ROOF DRAIN —I
SHOWER STALL N_ I� I
SERVICE/MOP SINK1 1 I d
TOILET
URINAL I - i � I_ li
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WASHING MACHINE CONNECTION II I I I 'I I ;I
WATER HEATER ALL TYPES _ 1
WATER PIPINCr ryI_
OTHER --II - - 1- - Q ,
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II I I 'I i1 I I I ' 1 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 9 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
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 collnce with all Pertine rovislon of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l-'"---
PLUMBER'S NAME Michael Maille LICENSE# 11355 SIGNATURE
MPD JP CORPORATION❑# PARTNERSHIP❑# LLC O# 3609
COMPANY NAIME HomeServe USA Energy Services NE LLC ADDRESS 5 Constitution Way
CITY Wobuml STATE MA ZIP 01801 TEL 781-359-2620
FAX i CELL EMAIL rachel.whittick@homeserveusa.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No ,/ �'
THIS APPLICATION SERVES AS THE PERMIT El gt.-P(A44 '� /6(/,2( '
FEE: $ PERMIT# J �// ��J
PLAN REVIEW NOTES 0/PC `-tet"/
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