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HomeMy WebLinkAboutBLDP-23-004341 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK el _ CITY YARMOUTH MA DATE 2/6/23 PERMIT# BLDP-23-004341 I JOBSITE ADDRESS 597 FOREST RD OWNER'S NAME TOWN OF YARMOUTH P OWNER ADDRESS CENTRAL DUMP 1146 ROUTE 28 SOUTH YARMOUTH,MA 02664-4463 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL 0 PRINT CLEARLY NEW: 0 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _URINAL WASHING MACHINE CONNECTION WATER HEATER 1 _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 El 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 0 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 William Gillespie LICENSE 1A865 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME WILLIAM M GILLESPIE ADDRESS 147 Blossom CITY Lynn STATE MA ZIP 019691626 TEL FAX CELL EMAIL bgillespie@irvineandsons.com } r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ..,mot_ � k CITY®Yarmouth„ 3- '1 3 `7 a;I_i=,. MA DATE r2102/23 PERMIT# Z JOBSITE ADDRESS,606 Forest Road(Disposal Scale House) ' OWNER'S NAMEI Town of Yarmouth POWNER ADDRESS 1146 Rt 28 South Yarmouth TEL 508-398-2231 i FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ei EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:0 REPLACEMENT:El EMERGENCY PLANS SUBMITTED: YES® NOD FIXTURES-1 FLOOR-' BSM 1 2 3 41 5 6 7 8 9 10 11 12 13 14 BATHTUB j _ CROSS CONNECTION DEVICE �. I.. r yrl . DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM INN I DISHWASHER DRINKING FOUNTAIN GPM FOOD DISPOSER . . ... FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) r KITCHEN SINK LAVATORY r. ROOF DRAIN �. :....__f SHOWER STALL SERVICE/MOP SINK 11.111 TOILET IM INKRIM IMAM MINN URINAL MBM WASHING MACHINE CONNECTION f WATER HEATER ALL TYPESElectric 6 Gal WATER PIPING OTHER r MUNI 1111,111111111111E INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 BOND ID 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 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 "thall Partine t rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME William M.Gillespie LICENSE# 10865 — SIGG SIGNATURE MP0 JP® CORPORATION0#FIRM PARTNERSHIP®#r LLC®# COMPANY NAME Robert W.Irvine&Sons Inc. ADDRESS 147 Blossom Street CITY Lynn ,j STATE IMIII ZIP 01902 TEL 781-581-0464 FAX 781-581-2860 CELL 1 EMAIL bgiilespie©irvineandsons.com