HomeMy WebLinkAboutBLDP-23-005096 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—_ CITY YARMOUTH MA DATE 3/15/23 PERMIT# BLDP-23-005096
4i JOBSITE ADDRESS 45 MOORING LN OWNER'S NAME DONAHUE KEVIN M
P OWNER ADDRESS DONAHUE CAROL PORTER P 0 BOX 213 WEST BROOKFIELD,MA 01585 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El
PRINT
CLEARLY NEW: m RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO m
FIXTURES z FLOORS—I 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/OIUSAND 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 1
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES m NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY III 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 119681 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME MICHAEL R MCBRIDE ADDRESS 9 Rustic Drive
CITY (West Yarmouth I STATE MA ZIP 02673 TEL
FAX I I CELL 1 I EMAIL stinger.mcbride@gmail.com
yam MASSACHUSETTS UNIFORM APPLICATION FOR ERMI TO PERFORM PLUMBING WORK
—'-�= " CITY Su f r a 0 MA DATE
ERM
/�/� OWNER'S NAME
JOBSITE ADDRESS q 5 / ' 00�l / q
OWNER ADDRESS -�/
P S��TEL��� /�J�6.j FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[ 5-
PRINT PLANS SUBMITTED: YES 0 NO
CLEARLY NEW:[W RENOVATION:12 REPLACEMENT:0
FIXTURES 7 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 GASIOIUSAND SYSTEM ,
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 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
{ OTHER PIPING G_ > 6 ' / /
f INSURANCE COVERAGE:
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL �. II
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 47•$p
LIABILITY INSURANCE POLICY l OTHER TYPE OF INDEMNITY 0 BOND 0 I MAR 15
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage require by J h�ter:1Zgf I MENT
I Massachusetts General Laws,and that my signature on this permit application waives this requirement. „ _____ _ -- -
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
-t 1 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 Plu bing ode and Chapter 142 o the(§ene I Laws. J,, / __)?
PLUMBERS NAME �l L 0 G U", C, r/ LICENSE# Jg6 / SIGNATURE
iv
'
MP❑ JP[ r3 I ADDRESS 37 f/g...1- 0 PORATION❑# CO ❑PARTNERSHIP # C 0#
COMPANY AME I ,�`` a � )/ r
CITYIY1 A i J STATE_.4* ZIP C) ?[a 0,/ TEL j ?id 7) �?
�t '� // re r is 0;- P4-J Lie'
FAX CELL EMAIL TcT I�'f �j 'C 4 C