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HomeMy WebLinkAboutBLDP-23-002186 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , nt CITY YARMOUTH MA DATE 10/24/22 PERMIT# BLDP-23-002186 JOBSITE ADDRESS 553 ROUTE 28 OWNERS NAME SHRIM INC • n OWNER ADDRESS C/O D/B/A HUNTERS GREEN MOTEL 553 ROUTE 28 WEST YARMOUTH,MA TEL r 02673 TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES z FLOORS--+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 37 37 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 37 37 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 37 37 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 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 William Horan LICENSE 1p269 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME WILLIAM T HORAN ADDRESS 1225 Plain St CITY Stoughton STATE IMA ZIP 020723157 TEL I FAX CELL I EMAIL alliedservices247@gmail.com i k 1 1 7 r MASSACHUSETTS UNIFORM APPLICATION FOR A PER IT TO PERFORM PLUMBING WORK `I=r� Fj __ CITY An M ' MA DATE 49 1 PERMIT# Z3— Zl C?Cc, JOBSI E ADDRESS 6'6 gTe �'e I,, OWNER'S NAME A M •�f t V POWNER ADDRESS ' N�1 I - e 1 `1 D V/S� • TEL 2 ? 1 ° FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[fr.' EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:El RENOVATION:1E4 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 17 3 1_ - _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM r--- DEDICATED WATER RECYCLE SYSTEM _ ''` DISHWASHER • vDRINKING FOUNTAIN FOOD DISPOSER V FLOOR I AREA DRAIN ,A. INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 3'� 3 7 • ROOF DRAIN • r SHOWER STALL SERVICE I MOP SINK Z! .TOILET ' ) . j URINAL ,j. WASHING MACHINE CONNECTION �J, WATER HEATER ALL TYPES - VJ WATER PIPING �; OTHER 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES eNO ❑ IA IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW J` UABIUTY INSURANCE POLICY 1,27 OTHER TYPE OF INDEMNITY 0 BOND 0 ct 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. r CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT L I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to he best of my knowledge and that all plumbing work an installations performed under the permit issued for this application will be in o ce witch all P i t vision of the Massachusetts State Plumbi Code and Chapter 142of thje General aws. . f��/ O PLUMBER'S NAME ' )//l d TI it A' LICENSE# SIGNATURE MP 07 JP 0 CORPORATION 0# PARTNERS IP❑.# LCEl# COMPANY NAME P 1Z:, D S56 v )�c S.. ADDRESS CITY 5--�4' b'IVA' STATEPL./ ZIP TEL TEL FAX b � CELL 9�0.%V,,7 EMAIL ,