HomeMy WebLinkAboutBLDP-23-001049 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=0 CITY YARMOUTH MA DATE 8/26/22 PERMIT# BLDP-23-001049
r ll JOBSITE ADDRESS 66 HOMERS DOCK RD OWNER'S NAME GLODIS PATRICIA A
p OWNER ADDRESS 66 HOMERS DOCK RD YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:m PLANS SUBMITTED: YES NO❑
FIXTURFS • 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
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❑ 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 El
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 Clay LICENSE 25993 SIGNATURE
MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME DAVID M CLAY ADDRESS PO BOX 383
CITY LEICESTER STATE MA ZIP 015240383 TEL
FAX CELL EMAIL clayplumbing@charter.net
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
7 _nlilil f'' CITY � cf�/ - MA DATE �--/, : PERMIT# 23-- /O ti,
JOBSITE ADDRESS y���, �
is _S I`0C y . OWNER'S NAME1,/ f � l C /66//1
POWNER ADDRESS 5 W r/c TEL id''_Y —Art0 O_
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL /
PRINT
CLEARLY NEW:D RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOU
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE �I
DEDICATED SPECIAL WASTE SYSTEM - m.. �1 I-... _. 1
1, ,
DEDICATED GAS/OIUSAND SYSTEM I�
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1 i
DEDICATED WATER RECYCLE SYSTEM • p
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
I
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
1 1
ROOF DRAIN I r IRV iiiii
�L 1
SHOWER STALL I
SERVICE MOP SINK im. 1 1
TOILET
URINAL
1111111111
WASHING MACHINE CONNECTION
1 1 11 11
WATER HEATER ALL TYPES
WATER PIPING
OTHER
r
_ I
111 I
I
it �
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO
0
IF YOU CHECKED YES,PLEASE INDICATE THE T F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY
BOND El
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 0 AGENT 0
I hereby certify that all of the details and information I have submitted or entered regarding this application . e to- and acc - e to the best of m nowledge
and that all plumbing work and installations performed under the permit issued for this application will be n compl-nce wi 'e pro s'• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - �/ �
Al i PLUMBER'S NAME I' I '' � LICENSE#
y vc— 1 — • GN.TUR r
MPD JP CORPORATION ID#I IPARTNERRSHIPD#I 1 LLCQ#
COMPANY NAME ' 144 CL / 1 ADDRESS I,;29!?`tet<14A/ /ci-F/-e
CITY STATE �l��i� ZIP
n 101 Say 1 TEL 1 SZ)X--, ,,,2-,"6,c " cii 1
FAX 1 CELL L EMAIL 16-4 41 LU wi/w ,T