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HomeMy WebLinkAboutBLDP-23-005314 ,4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' , CITY YARMOUTH MA DATE 3/28/23 PERMIT# BLDP-23-005314 ,e = JOBSITE ADDRESS 60 BROADWAY UNIT 14 OWNER'S NAME MEADOR DOREEN A P OWNER ADDRESS MEADOR C K&BROGNA D A A M 6 GUMWOOD LN WAKEFIELD,MA 01880-5130 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURFS z 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 _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL 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 0 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 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 ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME MICHAEL R MCBRIDE ADDRESS 9 Rustic Drive CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride@gmail.com . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �— _ A / MA DATE PERMIT*I:I— - CITY 2 2- S 3/'-1 JOBSITE ADDRESS kit, OWNER'S NAME •0(4- Q/ ) P OWNER DRESS DEL �Z/ -6&O1 FAX TYPE OR OCCUlK4f3E / CIIMM�CIAL R EDUCATIONAL ❑ RESIDENTIAL( j- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:X PLANS SUBMITTED: YES❑ NO 2 FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 6' 9 10 11 12 13 14 BATHTUB 1/Q4i .1- f 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 I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK '; t C+ = 1 ,f i TOILET / r_. _ URINAL . WASHING MACHINE CONNECTION a i WATER HEATER ALL TYPES } WATER PIPING BUILDING JE'A OTHER INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[la NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY 0 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. • SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 k-tI 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 Plumbi Code and Chapter 142 oft General Laws. \ !/li__ PLUMBER'S NAME I to ("k i;P) ('I LICENSE# I74'ft SIGNATURE MP 0 JP,© - A ORPORA ION 0# PARTNERSHIP❑.# LLC 0# COMPAN NAME Ar-iig_o ADD .3 C/JADDRESS 7r 74f)/iiei CITY �y�� Q 1 STATE ZIP Z jQ/ TEL 77 Y WO vet 2-Z FAX CELL EMAIL ,