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HomeMy WebLinkAboutBLDP-23-003322 A R� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t M, _ CITY YARMOUTH MA DATE 12/14/22 PERMIT# BLDP-23-003322 a l.<. �y JOBSITE ADDRESS 11 JOHN HALLS CARTPATH VILL OWNER'S NAME BEARSE SANFORD N P OWNER ADDRESS BEARSE MARCIA W 11 JOHN HALLS CARTPATH VILL YARMOUTH PORT,MA TEL 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES 1 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 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❑ 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 (David Whelan I LICENSEIV046 I SIGNATURE MP © JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME IDAVID A WHELAN I ADDRESS 152 schooner dr CITY ICOTUIT I STATE IMA I ZIP 1026353423 I TEL I FAX I I CELL I I I @gmailcom EMAIL daveawhelan . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK "CI J4Q NE D .`P�'3w+- ' , � .� 7/ MA DATE i 2 t/I //2 Z_ PERMIT# Z _ 3 3 -2 2- 0EC4641202QDR S' ice HA i_ C .0 779?T/i- OWNER'S NAME 043 i✓/ Wit- 62, -', / iblNGO1RRATDMDdS TEL FAX F_N TY e ' • 6 • COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL UY PRINT CLEARLY NEW:El RENOVATION: El REPLACEMENT:EY PLANS SUBMITTED: YES El NO El FIXTURES 7. FLOOR-0 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/OI.JSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK f LAVATORY 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 12"--NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 27 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 CHECK ONE ONLY: OWNER El AGENT El 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 c9t plianc ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME URA1:0 1/4/9&L14-' LICENSE# 13Dei 6 SIGNATURE MP E Y JP❑ CORPORATION L2# W 4.67 PARTNERSHIP El# LLC❑# COMPANY NAME G011.)l )21.id 3?vet ADDRESS __Q .Sef/���;,�-:�� 0/7 A Kr CITY i t) STATE PI ZIP D26 TEL '31./0 FAX CELL EMAIL