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HomeMy WebLinkAboutBLDP-22-000326 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY IYARMOUTH I MA DATE 17/19/21 I PERMIT# BLDP-22-000326 I � JOBSITE ADDRESS 124 LITTLE DIPPER LN I OWNER'S NAME KILMARTIN HUGH TRS OWNER ADDRESS 'KILMARTIN S&SAICH E&P TRS 4 KENTS LN HINGHAM,MA 02043 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT El CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO FIXTURES • FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: YES 0 NO 0 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY 0 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 'Douglas Langtry I LICENS4#1305 SIGNATURE MP JP CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I I © ❑ COMPANY NAME IDOUGLAS P LANGTRY I ADDRESS I1268 ROUTE 28 CITY IS YARMOUTH I STATE IMA I ZIP 1026644459 I TEL I FAX CELL I I EMAIL I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 0 4' 1_k - CITY 4 Lst4UUTh MA DATE 'lig bog PERMIT#gibP" 22-oo6 3 Lb t i 4 JOBSITE ADDRESS 2/ Li me, Di PPS L LL A JLFi. OWNER'S NAME' l4[...1~n Ii Lu OWNER ADDRESS 11 1 fS l Jul 9�I1 'A7 B'9 TEL lO FAX (� T' RE c O OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ✓r LLI NT'o CLEAR4. NEW:❑ RENOVATION:la- REPLACEMENT:❑ PLANS SUBMITTED: YES El NO El FIXIURFqCO CD T FLOOR—, 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 SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY Z 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❑■ 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. CHECK ONE ONLY: OWNER 0 AGENT 0 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 th st my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i com ' ce with all Pe ' ent p vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME DOUG LANGTRY LICENSE# 11305 G UR MP 0■ JP❑ CORPORATION El# PARTNERSHIP❑# LLC 0# 3081 COMPANY NAME AQUA SERVICES PLUMBING &HEATING ADDRESS 1200 ROUTE 28 CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-619-3367 FAX 508-619-3367 CELL EMAIL DOUG-AQUA@COMCAST.NET