HomeMy WebLinkAboutBLDP-21-006856 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
y=='cCITY YARMOUTH MA DATE 5/25/21 PERMIT# BLDP-21-006856
1;- JOBSITE ADDRESS 104 PLEASANT ST OWNERS NAME GREENE MARJORIE J TR(EST OF)
•� OWNER ADDRESS GREENE PLEASANT ST RLTY TRUST 40 CROSBY ST SOUTH YARMOUTH,MA TEL
02664
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 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 3 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 2 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER 1
WATER PIPING 1
OTHER 1
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 El OTHER TYPE OF INDEMNITY El BOND El
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 john gilmore LICENSE 18699 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME PLEASANT BAY PLUMBING INC ADDRESS
CITY BREWSTER STATE MA ZIP 02631 TEL
FAX CELL EMAIL PLEASNTBAYPLUMBING@COMCAST.NET
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEES S PERMIT#
PLAN REVIEW NOTES
I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_ ,i, CITY/TOW'>l4 *Q L. MA DATE ,Sy�2.4 PERMIT#
JOBSITE ADDRESS 161-1 OWNER'S NAME&C` ‘ti -
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:a. RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES,T NO❑
FIXTURES 7 FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB j
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY _75-
ROOF
5ROOF DRAIN
SHOWER STALL I
SERVICE/MOP SINK
TOILET f
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING f
OTHER CIwF s46a-__ {
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY( OTHER TYPE OF INDEMNITY ❑ 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.
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 ..s1.:0111.6,-,to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co �.li- c -11 e ' ent provision of the
Massachusetts State Plumbing- Code and Chapter 142 of the General Laws. •
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PLUMBER'S NAME• -�.L � �'-�"'L �- LICENSE# ���Icj %; SV' 'URE
MPS JP❑ CORPORATIOIIK1# ( �`{$Y PARTNERSHIP❑# LLC❑#
COMPANY NAME CIE `-\-- C ADDRESS � �•� � ��` ��C C
CITY ,c7 � ��=S STATE V~'t\--ZIP 6 2_C �� TEL
FAX CELL EMAIL \F �c>\u.