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HomeMy WebLinkAboutBLDP-22-001124 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -w - CITY YARMOUTH MA DATE 8/30/21 PERMIT# BLDP-22-001124 f <� JOBSITE ADDRESS 23 REFLECTION WAY OWNERS NAME KILROY ROBERT B P OWNER ADDRESS KILROY JOAN M 23 REFLECTION WAY SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURES • 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/OIL/SAND 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. YES 0 NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 (Michael Mcbride LICENSE 1681 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME MICHAEL R MCBRIDE ADDRESS 9 Rustic Drive CITY West Yarmouth STATE MA I ZIP 02673 TEL FAX ( I CELL EMAIL stinger.mcbride@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j CITY I . ,/ 41 .• ..c/ MA DATE illifr PERMIT# JOBSITE ADDRESS 23 pQRacrieN, (AA- y OWNER'S NAME ,+-� y — POWNER ADDRESS TEL 32.X6'6--FAX �`-' TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL I PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:RI, PLANS SUBMITTED: YES❑ NO fir FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 6• 9 10 11 12 13 4 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ J - DEDICATED GAS/01USAND SYSTEM - DEDICATED GREASE SYSTEM 1 DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER - DRINKING FOUNTAIN FOOD DISPOSER ' FLOOR l AREA DRAIN — - INTERCEPTOR(INTERIOR) KITCHEN SINK " LAVATORY r - ROOF DRAIN R C E I V E SHOWER STALL ( SERVICE/MOP SINK TOILET - AUG 2 7 2 URINAL �.._ . WASHING MACHINE CONNECTION arJi�l ING L1-Prf°FldlLiJi WATER HEATER ALL TYPES -- J WATER PIPING OTHER _ 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[$ NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Irk 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 1 Massachusetts General Laws,and that my signature on this permit aRlication waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT ❑ Z SIGNATURE OF OWNER OR AGENT L'I 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. q//-_ �(� ` PLUMBER'S NAME LICENSE#I/VI' . 1 SIGNATURE MP 0 JP K CORPORATION❑# PARTNERSHIP❑# roJ LLC❑# COMPANY NI IN(1 L A 11 (:) 4f ADDRESS ? v 91-16 0 r rye w CITY a r M O 0-14 STATE 'i\kit- ZIP © `'(2 7. TEL 7 7y $ID ?I 2 ( FAX CELL 77 1 </� 9722 EMAIL 54-t/lOr,.f Y\`-'3 r:410 O a<' ,M4•1L' coil d ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES •