HomeMy WebLinkAboutBLDP-23-001364 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 9/14/22 PERMIT# BLDP-23-001364
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-r_l_17 JOBSITE ADDRESS 40 MAYFLOWER TERR
OWNER'S NAME BERG PAUL C
P OWNER ADDRESS BERG LOIS J 40 MAYFLOWER TERR SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES El 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 1 1 2
ROOF DRAIN
SHOWER STALL 1 2
SERVICE/MOP SINK
TOILET 1 1 2
URINAL
WASHING MACHINE CONNECTION 1
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 El NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El 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 'Phu Huynh I LICENS0I519
SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP 0# I I LLC ❑# I I
COMPANY NAME IPHU HUYNH I ADDRESS 134 SCHLAGER AVE I
CITY IQUINCY I STATE IMA I ZIP 1021697447 I TEL I
FAX I J CELL I J
I EMAIL Ikntran8811@gmail.com
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1 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
oriM MA DATE d7-/3- 2 2- PERMIT# / 3�h
-JOUrftD' SS -.i'G) iC-/ `/vtxiP ei-r OWNER'S NAME S-.�
'PEP 131R D" SS c° /02 /G/crin c d f- c
� TEL /6 j� FAX
:ATE ICiRp E PQp9yP v Y TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Q-
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CLEARLY ` 'V: f: RENOVATION: REPLACEMENT:0
PLANS SUBMITTED: YES❑ NO EY
FIXTURES 1 FLOOR-i BSM 1 2 3 4 5 6 7 8' 9 10 11 12 13 BATHTUB 14
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-
1
LAVATORY / /
ROOF DRAIN
SHOWER STALL 4
SERVICE I MOP SINK
TOILET
j /
URINAL
. WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES / •
WATER PIPING
OTHER
INSURANCEI have a current liability insurance policy or its substantial equivalent en wh which meets the requirements of MGL Ch.142. YES,f
l'ff NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E 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 CHECK ONE ONLY: OWNER ❑ 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 wits all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 3/5----/9 "?‘":(
NATURE
MP❑ JP 2' CORPORATION 0# PARTNERSHIP❑#
COMPANY NAME LLC❑#
n ADDRESS y c %/e € ,4 v
CITY
STATE .C/A" ZIP c)02-/6 9
FAX TELG/�
CELL / 7 , j s� EMAIL K c) l-rry n 88 //