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HomeMy WebLinkAboutBLDP-23-004376 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 5 .z CITY YARMOUTH MA DATE 2/7/23 PERMIT# BLDP-23-004376 JOBSITE ADDRESS 10 RED JACKET RD OWNER'S NAME Margaret Kaney P OWNER ADDRESS 10 RED JACKET RD YARMOUTH PORT,MA 02675-1236 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES NO 0 FIXTURFS 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 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❑ 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 Timothy Galvin LICENSE 1A132 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME TIMOTHY W GALVIN ADDRESS 254 PHEASANT HILL CIR CITY COTUIT STATE MA ZIP 026352543 TEL FAX CELL EMAIL galvin.tim@gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK v . V- LC cS ++J MA DATE 2/ 72-3 PERMIT# 23 Li 3 7 L 1 0. ;r D- SS 10 i(! ti `ef is . OWNER'S NAME M&r a rei- ia✓) Pt.. [JEB 0%v .I,I P.;SS 5 lert44 -1 TE67 WI-3 - ��'L b FAX v vittitc DE06U t.; 1( PE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL,, CLEARLY NEW:0 RENOVATIO" REPLACEMENT:0 PLANS SUBMITTED: YES 0 N0g 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 1 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ' DISHWASHER - DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) - KITCHEN SINK LAVATORY I - - ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET / - URINAL WASHING MACHINE CONNECTION " WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Jel NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY,f f OTHER TYPE OF INDEMNITY ❑ BOND 0 i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 li 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 LA.I 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 come with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /� / `_ PLUMBER'S NAME 1 i tc.to(( 1/ C�/12 V/A/ LICENSE# /C�f 3 ��/ SIGNATUREMP� JP 0 / CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME ( I V t n r( ADDRESS 7- 17/(�' 't II d iY r CITY 0 Th-I 'T STATE /1 A ZIP o 2L' TEL,S-6 c'-Li/di( -3(70 FAX CELL EMAIL T 1 I/t r).-1/h-7 p 7 70 z r , Co?-,7