HomeMy WebLinkAboutBLDP-23-004428 7
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ill,=j CITY YARMOUTH MA DATE 2/9/23 PERMIT# BLDP-23-004428
rep
I' JOBSITE ADDRESS 42 FOUR SEASONS DR OWNER'S NAME MASON DORIS N TR
rso
P OWNER ADDRESS 42 FOUR SEASONS DRIVE SOUTH YARMOUTH,MA 02664-2136 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOORS— BSM 1 _ 2 3 4 5 6 , 7 I 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 1 _
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK 1 _ _
LAVATORY
ROOF DRAIN
SHOWER STALL
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 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 brian hibbard LICENSE#1977 SIGNATURE
MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME cape cod plumbing ADDRESS po box 429
CITY south dennis STATE MA ZIP 026600000 TEL 5083982228
FAX CELL EMAIL