No preview available
HomeMy WebLinkAboutBLDP-21-002929 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK E= e y, CITY YARMOUTH MA DATE 11/20/20 PERMIT# BLDP-21-002929 1 ,44 JOBSITE ADDRESS 99 BERRY AVE OWNERS NAME SVOBODA DOROTHY C P OWNER ADDRESS C/O DOROTHY W CLEAVELAND 99 BERRY AVE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES ..l FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 WATER PIPING 1 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El BOND❑ 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 Steven Traill LICENSE 21392 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME STEVEN J TRAILL ADDRESS 178 MALDEN ST CITY MALDEN STATE MA ZIP 021486519 TEL FAX CELL EMAIL � 4 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT El ❑ FEES$ PERMIT# PLAN REVIEW NOTES i �___.T.,— MASSAGIIUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 V� CIN f l) i2f)'iVTh1 MA DATE //—/?-. —2o PERMIT#sB t 2 21-1 )( 29 JOBSITE ADDRESS ? 9 23t��2 y 4Vt OWNER'S NAME 8r* '..erPel,V E P OWNER ADDRESS / / j //tJ;€3L) AIS ' TEL 4/1-Y2/ -lam/FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 5?" PRINT ,_,/ CLEARLY NEW:❑ RENOVATION:[J REPLACEMENT:❑ PLANS SUBMITTED: YES ErNO 0 FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1 ' DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM - DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ____, DISHWASHER / • DRINKING FOUNTAIN FOOD DISPOSER l FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY „Z - _ ROOF DRAIN SHOWER STALL / SERVICE/MOP SINK ` II TOILET - o + : .. ® I URINAL . WAS NG MACHINE CONNECTION / 1 ii 702f. I WATER HEATER ALL TYPES / WATER PIPING / / ti OTHER itpt311LDI k __--_ Dwp?ART 1 INSURANCE COVERAGE: ,11s I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Tr-NO 0 A IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �b1 / UABIUTY INSURANCE POLICY [f 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 \V 1 Massachusetts General Laws,and that my signature on this permit ap?lication waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 1AI I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to a best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in cpmpli with all Peril provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. titj( A.1( ' PLUMBER'S NAME LICENSE# 49 I?cl� SIGNATURE MP❑ JP Pf CORPORATION❑# PARTNERSHIP Q# LLC 0# COMPANY NAME h Ll'IIrtt�,L ADDRESS I 7t 1724/C/ 6 " CITY /71a/Wen STATE /A' ZIP QL/ilt" TEL -25-/- VZy---2 gi FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ R/P FEE: $ PERMIT# PLAN REVIEW NOTES 1 -7- 77 -c . TE/26:41 TiV k,), NT 72) GO Th2 ' LU thar ifr4T k (i? Avte- iq y -270v77-,-/ 4nA5 /r//,) , elipP - RECEIVED LJUL 27 2021 BUILDING DEPARTMENT By - - -