HomeMy WebLinkAboutBLDP-19-000605 1
I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Oa CITY YARMOUTH I 1 MA DATE 7/30/18 PERMIT# BLDP-19-000605
JOBSITE ADDRESS 32'PA VIET RD OWNER'S NAME WOFFORD ROSE ANN L
p OWNER ADDRESS 18 LEXINGTON AVE HAVERHILL, MA 01835 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOORS—r BSM 1 2 3 4 5 6 7 8 9 10 11 12 , 13 14
BATHTUB
CROSS CONNECTION DEVICE _ _ _ _ _ _ _
DEDICATED SPECIAL WASTE SYSTEM •
DEDICATED GAS/OIL/SAND SYSTEM I
DEDICATED GREASE SYSTEM I
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE I
DISHWASHER
DRINKING FOUNTAIN I _ _ _ _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL �
SERVICE/MOP SINK i
TOILET I 1 — _ _
URINAL _ _ __
WASHING MACHINE CONNECTION
WATER HEATER 1
WATER PIPING _
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability Insurance policy or ts substantial equivalent which meets the requirements of MGL Ch.142. YES N NO 0
I1
IF YOU CHECKED YES,PLEASE INDICATE THE PEIOF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY m 0 HER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER: I am a an tha�the licensee does not have the insurance coverage required by Chapter 142 of
the Massachusetts General Laws,and tha m sig ature on this permit application waives this requirement.
SIGNATURE OF OWNER Or AGENT
I hereby certify that all of the details and infomtalion I havsubmitted or entered regarding this application are true and accurate to the best of my
knowledge and that all plumbing work and Installations pe(formed under the permit issued for this application will be In compliance with all Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 1142 of the General Laws.
PLUMBER'S NAME Anthony Cooper LICENSE&2048 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ANTHONY J COOPER ADDRESS 66 CHUCKLES WAY
CITY MARSTONS MLS STATE MA ZIP 026481583 TEL L
FAX CELL I EMAIL
LR 1/-
.
•
ROUG11 PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY I FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
Drnssrr
FEESS PERMIT#
PLAN REVIEW NOTES
•mismo