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HomeMy WebLinkAboutBLDP-21-006803i vile MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE 15124121 I PERMIT# BLDP-21-006803 El- k,,,, YARMOUTH 1 1 �_-_E, CITY OWNER'S NAME 1paula cruz JOBSITE ADDRESS 115 WEBSTER RD ♦sp P OWNER ADDRESS IMA 02048-2924 'TEL 1 I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES EI NO❑ FIXTURES FLOORS—, BSM 0©© 4 © 6 0 8 9 10 m 12 ® 14 BATHTUB __�_-_=__�_____ CROSS CONNECTION DEVICE ______ DEDICATED SPECIAL WASTE SYSTEM _11111____====___ _ 111111111111 MINIM DEDICATED GAS/OIUSAND SYSTEM _____- DEDICATED GREASE SYSTEM ______===______ 11111 Mil 111111111111 DEDICATED GRAY WATER SYSTEM ______ DEDICATED WATER RECYCLE SYSTE IIIMM1111I111II1I1II11I11IMNM1IM1I DISHWASHER _ 1 ___ DRINKING FOUNTAIN ______=____�___ 111111111111111111M MI FOOD DISPOSER _____ FLOOR/AREA DRAIN ______=-___�___ INTERCEPTOR INTERIOR ______ KITCHEN SINK 1111111111111111111111111111111111111111111111111111111111111111 _—_—_— LAVATORY 111111111111/111111111111111111111111•1111111111111111 ��_ ROOF DRAIN ____ ____�____ SHOWER STALL _�___ SERVICE/MOP SINK IIN1I1111I11I1IIIIIII1III1IIIII1IIIIIIIII1IIIIIII—___ TOILET _ NM_ URINAL ___1111111111MINIIIIIIIIIMIIIIIIIIIIII Ell _________ WASHING MACHINE CONNECTION 0_____ 11111111111111111111111111111111111111111111111111111111111 NM WATER PIPING ___- 111111111111111111111111111111111111111 MINI OTHER ___ 1.1111111.111111.11.1.111.1.11Mini all OTHER DESCRIPTION: INSURANCE COVERAGE: YES 0 NO C3I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 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. PLUMBERS NAME 'Ryan White I LICENS416068 I SIGNATURE MP 0 JP 0 CORPORATION ❑# I I PARTNERSHIP C3# I 1 LLC CI# I I I COMPANY NAME (RYAN L WHITE 1 ADDRESS 119 SKIPPERS DR CITY 'Harwich I STATE IMA 1 ZIP 1026453122 1 TEL 1 1 FAX 1 1 CELL I 1 EMAIL Irwhite1011@gmail.com I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY ' FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT Ei FEES$ PERMIT# PLAN REVIEW NOTES