HomeMy WebLinkAboutBLDP-16-003836 / i,7r. B/ Gyv7 // f' r/ t(1/01 ST // 17U
- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
uj f , CITY'Yarmouth MA DATE 12/30/2015 PERMIT# P"4` 058%
JOBSITE ADDRESS 4 Orchid Street OWNER'S NAME Heather and Matt Childs
P OWNER ADDRESS j W.Yarmouth TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW:[1 RENOVATION:[2_,f REPLACEMENT:U PLANS SUBMITTED: YES C NO[J
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 I 9 10 11 12 13 14
BATHTUB 1 1 1 i 1 J 1 I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM I I
DEDICATED GAS/OIL/SAND SYSTEM 1 I I j
DEDICATED GREASE SYSTEM I
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM I3
DISHWASHER
DRINKING FOUNTAIN I 4 I
FOOD DISPOSER
FLOOR/AREA DRAIN ( ! I
INTERCEPTOR(INTERIOR) I 11 I j II
KITCHEN SINK
LAVATORY 1 1 j 1 1 1 i J 1 i
ROOF DRAIN [
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL 1 I [ I
WASHING MACHINE CONNECTION 1 1 1 1 1 1
WATER HEATER ALL TYPES [ ! [
WATER PIPING 1 1 j i
OTHER I
. I ,
I I ; ,.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES C NO ri
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY C OTHER TYPE OF INDEMNITY ❑ BOND ❑ c/1!ffitiero igx cc
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 accurat to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in lia Provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Peter J.Hassett LICENSE# 11682 SIGNATURE
MP 0 JP CORPORATION n# 3506 PARTNERSHIP U# LLC LJ#
COMPANY NAME Hassett Plumbing and Heating,Inc. ADDRESS 8 Skipper Lane
CITY Yarmouth Port STATE MA ZIP 02675 TEL 508-744-7555
FAX CELL 508-237-2175 EMAIL hassett357m@msn.com
i
ti
' ;. s
6
b
� �