HomeMy WebLinkAboutBLDP-18-007393 (3) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 6/28/18 PERMIT# BLDP-18-007393
JOBSITE ADDRESS 24 BRATTLE DR OWNER'S NAME SMITH GREGORY
P OWNER ADDRESS GULLIVER-SMITH LORI E 1242 NORTH CHESTNUT AVE ARLINGTON HEIGHTS,IL TEL
60004
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL f Y
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CLEARLY NEW:n RENOVATION:n REPLACEMENT:M PLANS SUBMITTED: YESn NO171
FIXTURES i 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
ROOF DRAIN
SHOWER STALL _
SERVICE/MOP SINK _
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER 1
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. YESF1 NO n
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYn BONDn
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 Keith Farnham LICENSE141601 SIGNATURE
MP IM JP n CORPORATION f PARTNERSHIP LLC
COMPANY NAME KEITH J FARNHAM ADDRESS 4 JUNIPER HILL RD
CITY EAST SANDWICH STATE MA ZIP 025371036 TEL
FAX CELL EMAIL
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