Loading...
HomeMy WebLinkAboutBLDP-23-005098 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK v,--c CITY YARMOUTH MA DATE 3/15/23 PERMIT# BLDP 23 005098 I JOBSITE ADDRESS 48 MONROE LN OWNER'S NAME JEFFREY JOHNSON P OWNER ADDRESS !CATHERINE JOHNSON 48 MONROE LN WEST YARMOUTH 026730000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL E PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YESD NO m FIXTURES z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 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 ROOF DRAIN SHOWER STALL 1 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© 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 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. PLUMBERS NAME Michael Mcbride LICENSE 119681 SIGNATURE MP 0 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 , �/ am_ -' CITY C(, 1`1 d v "�� MA DATE —il U PER T#j 1 23`06 so- _ JOBSITE ADDRESS f M 0 n L( OWNER'S NAME \-_±e__PP"-TO I`( n ,S on OWNER ADDRESS 61 C. TEL t f ! 7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES[ NO 0 FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8' 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM — DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM J • 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 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER i • INSURANCE COVERAGE: �; I have a current liability insurance policy or its substantial equivalent which meets the requirements of NI?C i�t.1�2.EEL ViOrh IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO • 15 2023 UABIUTY INSURANCE POUCY OTHER TYPE OF INDEMNITY'❑ BOND 0 3S"U r e � t�el�`d$Td� T OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage ea�y b� j Massachusetts General Laws,and that my signature on this permit application waives this requiremen_. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 wi all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME p �.� () LICENSE# SIGNATURE MP❑ JP( CORPO TION❑—#— PARTNERSHIP❑# C❑# E V.J fl(. J ADDRESS 7�qA 1, 1 4` " L COMPANY (\I\ —37 CITY a /✓1 l 5 STATE_hitZIP 0 (.� ,1( TEL 7 2 a-r 0 /c/L FAX CELL EMAIL 5 f� e• c- LR ® r/tc C '