HomeMy WebLinkAboutP-19-1082 jr MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 8/22/18 PERMIT# BLDP-19-001082
JOBSITE ADDRESS 18 MYRTLE LN OWNER'S NAME BANKS CAROLYN E
P OWNER ADDRESS 208 CARLSON LN W BARNSTABLE,MA 02668 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
FIXTURFS 1 FLOORS— ,BSM 1 2 3 ; 4 5 , 6 7 8 9 , 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
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 1
WATER PIPING
OTHER
OTHER DESCRIPTION:WH,backflow
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES m NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY m OTHER TYPE OF INDEMNITY 0 BOND 0
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.
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.
PLUMBER'S NAME Dmitri Chalice LICENSE 8727 SIGNATURE
MP 0 JP 0 CORPORATION m# 3727 - PARTNERSHIP ❑# L LLC ❑#
• COMPANY NAME Seaside Gas Service Inc ADDRESS 67 HELMSMAN DRIVE
CITY YARMOUTH STATE MA ZIP 02675 TEL
FAX CELL EMAIL
• �r
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES •
Yes No
THIS APPLICATION SERVE AS THE E
DCD\IIT
FEESS PERMIT#
PLAN REVIEW NOTES
$4--'444c,
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