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Home My WebLink AboutBLDP-21-006423 �., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK c. tk,, , CITY YARMOUTH MA DATE 5/6/21 PERMIT# BLDP-21-006423 1069 GREAT ISLAND RD '� JOBSITE ADDRESS OWNER'S NAME NOLEN WILSON - P OWNER ADDRESS 1120 5TH AVE APT 10B NEW YORK,NY 10128-0144 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 2 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 2 LAVATORY 1 7 2 ROOF DRAIN SHOWER STALL 1 4 2 SERVICE/MOP SINK TOILET 1 5 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 2 WATER PIPING OTHER 1 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❑ 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 William Woods LICENSE#1887 SIGNATURE MP 0 JP 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME WILLIAM T WOODS ADDRESS PO BOX 702 CITY W BARNSTABLE STATE MA ZIP 026680702 TEL FAX CELL EMAIL mAr: ,10 iec # . ow I, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK n— � AAA-DATE jj S- - rr � _ ' CITY l^ c ! f / t PERAI®T JOBSITE ADDRESS V�6, / _G Z1n, Ai((OWNER'S NAAAE J k eh f' 1 , 1 OWNER ADDRESS - Si$uNe, 6 / 4/'k4 I TEL FAX J 1 TYPE OR OCCUPANCY COA+1tiiE RCIAL(i EDUCATIONAL ❑ RESIDENTIAL la ' PRINT CLEARLY NEW: RENOVAT h 0 REPLACEMENT:Q PLANS SUBMITTED: YES NOQ FIXTURES 1 FLOOR-' { B_1 1 2 .. 3 1 4 I _5 1 3 7 3 9 1 10 111 12 1. 13.1. 14 BATHTUB CROSS CONN>=CTIau DEVICE _ =- DEDICATE?SPECIAL WASTE SYSTEM DEDICATED GAS/Olt/SAND SYSTEM DEDICATED CREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEMAtt DISHWASHER • ' DRINKING FOINTA�t - , - - FOOD DISPOSER -,, --ADINISIMMAII, __. Ir.,.-- to. FLOOR/AREA DRAIN KITCHENINTERCEPTOR SINOK(INTERIOR) — LAVATORY - _.}, ROOF DRAIN SHOWER STALL .j , 1-,. ,�__ SERVICE/MOP SINK TO -_ URINAL 1 WASHING MACHINE CONNECTIONY R WATER HEATER ALL TYPES 1 WATER PIPING RI = OTHER I Y WSURANCE COVERAGE: � t I have a current liability insurance poky or Ks t hrm tt whiceets the requirementsof MGL Ch.142 YES LiiJ NO IF YOU CHECKED YES,PLEASE INDICATE TtE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L3 OTHER TYPE OF INDEMNITY OWNER'S INSURANCE WAIVE 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 perms appkation waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT Q SIGNATURE OF OWNER OR AGENT ` I hereby cerSEy that all of the deters and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbhg work and it bons performed under the permit hawed for this application wit be in compNance wkh at Pertinent of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��2��,, 411t P-T PLUMB 1 11(Ak � - I LI SE#1/!Sy A SIGNATURE • MP It.JP U CORPOR ATION PARTNERSHiPD#1 (LLC 0#1 - COMPANY NAME 11 — 6,16 - t R /,pot"a S pia/n6/ 5 I ADDRESS 1 P) 7' Cn Y1 W,,�3, 4 :: (STATE I MA--I zz{P 1 o v`,6 ( I TEL LTas X 7 38Stf # FAX 14Q E C®1:1367,7858 I UA I iitAg it -/IS eaGil/it a Are-