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Home My WebLink AboutBLDP-22-005813` w MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w e, CITY YARMOUTH MA DATE 4/12/22 PERMIT# BLDP-22-005813 ' g JOBSITE ADDRESS 59 CARVER RD OWNER'S NAME James Toomey D OWNER ADDRESS 02062 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL al PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES • 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/OIUSAND 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 2 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER WATER PIPING 1 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 ❑ 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 !Gregory Selfe LICENSE 26714 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME GREGORY A SELFE ADDRESS 41 SPRINGER LN CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL ! FAX CELL EMAIL K , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �_-,�_, CITY YARM4K-f N MA DATE 41- I(-aa• 2"L- PERMIT# S Y1 JOBSITE ADDRESS S9 CIS RV Cr- GAD OWNER'S NAME /�e .., POWNER ADDRESS S9 CA kt ee Ropy TEL0°K)TTC-ti746. FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION:5il REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 1 10 11 12 13 BATHTUB I 14 CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM L DEDICATED GAS/OIL/SAND SYSTEM - _ DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM _________ DISHWASHER I - DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ____ KITCHEN SINK { _____ LAVATORY ROOF AVA DRAIN a I R F � , F I V D �� SHOWER STALL SERVICE/MOP SINK Aft 1 i 622 TOILET a _ URINAL ` WASHING MACHINE CONNECTION f a BTILDING DE WATER HEATER ALL TYPES WATER PIPING / -_____,___- OTHER 4 INSURANCE COVERAGE: l I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESV NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY rie 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 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 kA.t 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. S PLUMBER'S NAME6eFF6oty Se ifc LICENSE#a61/y . SIGNATURE MP❑ JP EN CORPORATION 0# PARTNERSHIP❑.# LLC❑# COMPANY.NAME 6fFi4O y Sc(C p lW 4r �c> 4 ADDRESS Lit SPRI O 6/42.Af to CITY L YACt , STATE go- ZIP 04-6 73 TEL S°e) Y --"Y 3 ( FAX CEL(f"e)" /43AY EMAIL SC(Fe34rt g C 100•4*M CV 413 r I30