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HomeMy WebLinkAboutBLDP-23-005217 v1/4MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 3/22/23 PERMIT# BLDP 23 005217 JOBSITE ADDRESS 13 WALTHAM CIR OWNER'S NAME HOLLINGSWORTH BENJAMIN ERIC P OWNER ADDRESS HOLLINGSWORTH B J&WM&J CAHILL 13 WALTHAM CIR WEST YARMOUTH,MA TEL 02673 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES NO m FIXTURES I FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 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 El 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 0 BOND El 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 Daniel Smith LICENSE 314996 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 79 East Osterville Dr CITY Osterville STATE MA ZIP 02655 TEL FAX CELL 8578809696 EMAIL DANIELL12plumber@GMAIL.COM • _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK PER I 1_i_ CITY`AA IL e(K to MA DATE -Z I -Z 3 , - Z 3-D D li / JOBSITE ADDRESS a g t A t TtlAi✓1 e�Ci� OWNER'S NAME OLL .P ties Gv2-7- OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALa PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0 FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8' 9 10 0 12 13 14 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM -- DEDICATED GAS/OILISAND SYSTEM MIEN DEDICATED GREASE SYSTEMIIIIIDEDICATED GRAY WATER SYSTEM In DEDICATED WATER RECYCLE SYSTEMMIN 111.1111.1.1 DISHWASHER DRINKING FOUNTAIN • -=- FOOD DISPOSER r- _ FLOOR/AREA DRAIN INTERCEPTOR INTERIOR) -=-- LAVATORY = ROOFERST _ Tr;� merimmil SHOWER STALL r ���++��!!__� SERVICE/MOP SINK �� TOILET m ,ra�� IIII IIMMIMIIII WASHING MACHINE CONNECTION EPAR av: �� ■ OTHER 11.1111.0111111 INSURANCE COVERAGE: 1111111111111.1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 50. NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 0 LIABILITY INSURANCE POUCY R OTHER TYPE OF INDEMNITY ❑ BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not the insurance coverage required b Cha ter Massachusetts General Laws,and that my signature on this permit application waives this requirement. y p 142 of the SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑ 1-1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and and that all plumbing work and installations performed under the permit issued for this application will be in compliance with Massachusetts State Plumbing Code and Chapter 142 of the General Laws. accurate to the best of my knowledge p eminent provision of the PLUMBER'S NAME 1OA1J � M Lt Z S ti 3 LICENSE# 11.34` 1 cc, _-� SIGNATURE MP❑ JP 0 CORPORATION❑# PARTNERSHIP❑.# COMPANY NAME l��'S Ql ?M d� SN LLC 0# ADDRESS 75 BAST GSCru��k (2--v CITY sCISt6Q_ust, � STATE FAX -- ZIP 6�Cq_ TELCJ7 �$O� 5(oq0 CELL EMAIL ���Zk_ itt • 30— Cf9S