HomeMy WebLinkAboutBLDP-23-003264 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,1/49 CITY YARMOUTH MA DATE 12/12/22 PERMIT# BLDP-23-003264
!! JOBSITE ADDRESS 10 CLIFFORD ST OWNERS NAME O'PACKI PETER F JR
OWNER ADDRESS O'PACKI PATRICIA 50 BELLVISTA RD WORCESTER,MA 01682 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
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 1
ROOF DRAIN
SHOWER STALL 1
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❑ NO ❑
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 Jared Wilber LICENSE 1)5219 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME JARED WILBER ADDRESS 474 WINSLOW GRAY RD
CITY S YARMOUTH STATE MA ZIP 026644317 TEL
FAX CELL EMAIL jarbemie123@gmail.com
.'-� •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
/ CITY 1 ci,y" eii r( +-, MA DATE j 2 -i 2- —2 2_. PERMIT# 2-1— 324"ti
JOBSITE ADDRESS I > C / 1, 1 .Pp(1^-p_ SJ 1' OWNER'S NAME C-f pi -c 1'
P OWNER ADDRESS 44 if) e TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL al.--
PRINT
CLEARLY NEW:❑ RENOVATION:Er REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1. FLOOR—► BSM 1 2 3 4 5 6 7 6' 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _ _
DEDICATED GAS/OILISAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER _ _
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR) T
_
KITCHEN SINK
LAVATORY R F C I Vic a
ROOF DRAIN _
SHOWER STALL _ 4' • EC12
SERVICE/MOP SINK
TOILET i`
URINAL 3U IUD ING U'"PAF21 MEN I
WASHING MACHINE CONNECTION _ Y
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 0 NO Er-
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
LI 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 Preitinen provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I I L C,41 G-e'l.._
PLUMBER'S NAME 3-(NC C.et- ► �Y LICENSE# I o2 I ( i SIGNATURE
MP LJa JP❑ CORPORATION Q PARTNERSHIP❑.# `` LLC 0#
COMPANY NAME 3-(VC 0 S e li.,, . Ns, ADDRESS �! 7 U i s io w C.-1 Ait e
l c t_r (/ (. STATE 1 - ZIP G 2 (,' 4 TEL 5 S_2 3 711 V/
CITY Y� , ,
FAX CELL _cC.t,i1n-e- EMAIL ALI e,'T*IOC 12 I e q m0.Jf, 6
s01
• CVV 324, D