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HomeMy WebLinkAboutBLDP-23-005474 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK kna CITY 'YARMOUTH MA DATE 4/3/23 PERMIT# BLDP-23-005474 JOBSITE ADDRESS 6 TOWN HALL AVE OWNER'S NAME BOWSER ANNA (LIFE ESTATE) P OWNER ADDRESS CIO STEVE BOWSER 1 GLENGARY RD CROTON ON HUDSON,NY 10520-2139 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURES z 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 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 ❑ 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. 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 119681 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME MICHAEL R MCBRIDE ADDRESS 19 Rustic Drive CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride@gmail.com il fQ►. P i Jr �1 MASSACHUSETTS UNIFORM APPLICATION FO R R A PERMIT TO PERFORM PLUMBING WORK =`7°- CITY 50 G 1"!/ eiV i MA DATE =_,I]= __ / _ PERMIT# bJOBSITE ADDRESS 6, I�Cj/,/� ,9—J�r ho L OWNER'S NAME 1_c�Ur4 O co St=/— POWNER ADDRESS `"���'" g / v TEL 7 Y1 `43/2 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[ PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:ail, PLANS SUBMITTED: YES❑ NO 0 FIXTURES 1 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 GAS101USAND SYSTEM • DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER I • DRINKING FOUNTAIN FOOD DISPOSER FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY ROOF DRAIN ' RECEIVED SHOWER STALL SERVICE/MOP SINK TOILET URINAL MAR 3 0 2023 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES BUiLuiNG 3LPMr NT WATER PIPING o, OTHER INSURANCE GE: I have a current liability insurance policy or its substantial equivalent h which meets the requirements of MGL Ch.142. YES fy NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY [k 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 CHECK ONE ONLY: OWNER ❑ AGENT 0 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 pr vision of the Massachusetts State Pi m ing de and Chapter 142 of the Gen I Laws. PLUMBER'S NAME k.C--ccP L 4 r f LICENSE# 7 .i / 1 SIGNATURE MP 0 JP t.j/ CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPA7 AME t, CY:3 r I 4 P-1-4./.. ADDRESS � 7 rc,A Li(ti c 7-(J e4 y r CITY ./I ,/ 5._ STATE ZIP t'J 7 6(}/ TEL FAX CELL r EMAIL /1�f� . � /4 [/