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HomeMy WebLinkAboutBLDP-22-006704 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Ge CITY YARMOUTH MA DATE 5/19/22 PERMIT# BLDP-22-006704 JOBSITE ADDRESS 141 HIGHBANK RD OWNER'S NAME HIGHBANK PROPERTIES INC P OWNER ADDRESS CIO BLACK ALEX 141 HIGHBANK RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: m RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURFS • FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 19 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 LAVATORY 1 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION:outdoor shower INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 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 199681 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 E '""`- -_ E ®A SSACHUSETTS UNIFORM APPLICATION FOR A PE' -IT TO PERFORM GAS FITTING _ ��' WORK -, s: 212�ITY eu MA DATE , r Z- PERMIT# Z2—c`l0 JOB TE ADDRESS L `/ B ILDI EPA'TMENT �� DINNER'S NAME By- AA •. 'DDRESS E-CoAALL 1-4G/6 r • )) TYPE OR S / or TEL `�"-5 L FAX PRINT OCCUPANCY TYPE OMI�IERCIAL 61° ?� EDUCATIONAL CLEARLY ❑ RE RESIDENTIAL NEW:❑ RENOVATION: 0. REPLACEMENT: a � c PLANS SUBMITTED: YES W.I. NO❑ APPLIANCE„ FLOORS—f 6SM t BOILER -- 4 5 6 9 ®® 13 14 BOOSTER � - - ....s...... . aiCONVERSION BURNER DIRECT V NTE HEATER -- == IIIIIIIIIIIIIIIIII DRYER --_MN FIREPLACE _111111111111 � FRYOLATOR rill FURNACE GENERATOR —= 1111.11111111111. INIIIIFRARED HEATER = LABORATORY COCKS IIIIII MAKEUP AIR UNIT �= . OVEN ==--_a POOL HEATERmil. � ROOM/SPACE HEATER _ ROOF TOP UNIT __� - nil__- 11111111 UN�JEIJTED ROOM HEF�TER _ WATER HEATER �__C`_ OTHER .. Ell=:aliallillinill" haveI ...= 0maim,a current liabli insu INSURANCE COVERAGE �i rance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES N NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY 116• OTHER TYPE 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 AGENTCHECK ONE ONLY: OWNER 0 AGENT 0 "i. I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate `',` and that all plumbing work and installations performed under the permit issued for this application will be in compliance �` Massachusetts State Plumbing Code and hapter i42 of the General Laws. to the best of myknowledge 'fib with all Pertinent provision of the PLUMBER-GASFITTER NAME 1 ALCk4 a2 �- c r 1 MP❑ MGF JP LICENSE# ��a - SIGNATURE tf JGF❑ LPGI ❑ CORPORATION❑¢{ PARTNERSHIP❑ LLC 0 COMPANY NAME (' Hi-- ADDRESS 3 Fr.., n (,G�j e7 CITY —n I STATE ZIP 1 FAX TEL_ D q a I `ZZ CELL EMAIL c t i 1 l - I AI