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HomeMy WebLinkAboutBLDE-23-000667 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ZI, / CITY YARMOUTH MA DATE 8/9/22 PERMIT# BLDP-23-000667 1' JOBSITE ADDRESS 16 ELDRIDGE RD OWNER'S NAME SIELAND FREDERICK P OWNER ADDRESS SIELAND KARIN 184 MOUNTAIN RD PLEASANTVILLE,NY 10570 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS-4 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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❑ NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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. PLUMBER'S NAME Michael Mcbride LICENSE 10681 SIGNATURE MP 0 JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME MICHAEL R MCBRIDE ADDRESS 9 Rustic Drive CITY West Yarmouth STATE MA ZIP 02673 TEL FAX I CELL EMAIL stinger.mcbride@gmail.com • MASSACHUSETTS UNIFORM APPLICATION FOR A -E- IT TO PERFORM PLUMBING WORK ' i= I VIE l>' A ., adMA DATE A C.Z- PERMIT#Z3_040 Co`) AUG 5 nJJ�BSI—E DDRESS Mfri, // C _,� �" �ER'S NAME 12.0 5 A,� OW :• ,'DRESS : 4i 4 EL0���� Y3,75FAX B ILDIEDEPARTM . =--_•: • -' CYTYPE COMMERCIAL ■ EDUCATIONAL ❑ RESIDENTIAL 1-08r, PRINT CLEARLY NEW:❑ RENOVATION:[gl REPLACEMENT:❑ PLANS SUBMITTED: YES E4, NO 0 FIXTURES 7 FLOOR-4 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 SYSTEM " DISHWASHER . " DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY /� � T ROOF DRAIN SHOWER STALL / - SERVICE I MOP SINK TOILET I ` URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ill NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY 2 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 application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 1-1.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 1�application will be in compliance with all Pertin nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.1 1 _.S---t(�(— L PLUMBER'S NAME LIC NSE# . SIGNATURE MP❑ JP❑ C ORATI N 0# PARTNERSHIP❑.# 0 COMPAN AME r t I /,� /g ADDRESS37 r GnL.z/ LLC # A- te. CITY M a ifyi I S STATE__ ZIP 6 e/ TEL 77 e 7I D (2/ e-2. FAX CELL 77yVO l/tZ- EMAIL • riscOfi 0044-k`e04,