HomeMy WebLinkAboutBLDP-19-003498 •
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY0111Nk MA DATE k'&110111-666�l0�1k'&110111- PERMR#/ 0/�-/P-Oojy
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JOBSITE DRESS « (sr?) (/ OWNER'S NAME Yt Cl YW crce II U
POWNER ADDRESS TEL Sag 9cF; C917 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[xI
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
--2--FICTDFLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
(15 -13;71:1F7
1
CS SON ECTION DEVICE
DATED' PECIAL WASTE SYSTEM
DIQICATED GAS/OIUSAND SYSTEM
W I DEDICATED UREASE SYSTEM
o j PP: CATED GRAY WATER SYSTEM •
n i lit P a:ICATED PATER RECYCLE SYSTEM
DISHWASHER -
DRINKING FOUNTAIN
FOOD DISPOSER
OOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
I LAVATORY 1 -
ROOF DRAIN
I SHOWER STALL `
I SERVICE I MOP SINK _
i TOILET
URINAL
• 1 WASHING MACHINE CONNECTION t
I WATER HEATER ALL TYPES
WATER PIPING
I OTHER •
iI
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES V NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY cr OTHERTYPEOF INDEMNITY 0 BOND 0
• OWNER'S INSURANC AIVER:I am aware thatthe licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts Ge •ral . s,and that my signature on this permit application waives this requirement. /
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r a CHECK ONE ONLY: OWNER Q AGENT ❑
/Kr •T '+ OF OWNER OR AGENT
141 I hereby cert i I at all of the details and information I have submitted or entered regarding this application are true and accurate tot est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compile ' all 'nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 5'.35V: %{°05 LICENSE# 3a9I'a.. SIGNATURE
MP❑ • JP er
1 f r CORPORATION❑# PARTNERSHIP 0.�# 1 LLC 0#
COMPANY NAME .. Glzaq aW1�Ji in M ADDRESS 63 5w,cf' Qpm Ie- V c)
CITY J. 9.(Wkoui4, J STATE I/`4- ZIP °XL64 TEL 503 a3) 369/
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FAX CELL EMAIL 9 f+ I "4.14 �i✓WO Ge
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ROUGH PLUMBING INSPECTION NOTES pELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
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1124 £: c-
/ /L� THIS APPLICATION SERVES AS THE PERMIT 0 0
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/1/3/1/(/ rl FEE: $ PERMITS
ELAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 12/10/18 PERMIT# BLDP-19-003498
F a IL=J JOBSITE ADDRESS 11 CAROL RD OWNER'S NAME GURSHA JAMES P
P OWNER ADDRESS C/O FARRAR CODY J 515 EAST HARTFORD AVE UXBRIDGE,MA 01569 —EL
TYPE OR OCCUPANCY TYPE COMMERCIAL n RESIDENTIAL rn
PRINT
CLEARLY NEW: RENOVATION:[] REPLACEMENT:n PLANS SUBMITTED: YESn N01-71
FIXTURES 1 FLOORS—. 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/OIUSAND 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 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
WATER PIPING
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESP1 NO ri
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYE BONDER
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.
PLUMBERS NAME Justin Hogg LICENSE3i'412 SIGNATURE
MP n JP 71 CORPORATION p PARTNERSHIP nit LLC r
COMPANY NAME JUSTIN S HOGG ADDRESS 25 PITCH PINE RD
CITY BREWSTER STATE MA ZIP 026312348 TEL
FAX CELL EMAIL
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