Loading...
HomeMy WebLinkAboutBLDP-23-004010 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a CITY YARMOUTH MA DATE 1/23/23 PERMIT# BLDP-23-004010 t i JOBSITE ADDRESS 9 OLD CASTLE RD OWNER'S NAME HAGER JOANNE L P OWNER ADDRESS 9 OLD CASTLE RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 2 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 2 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 0 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 Kevin Spry LICENSE 16964 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME KEVIN E SPRY ADDRESS 42 CYNTHIA DR CITY RAYNHAM STATE MA ZIP 027671503 TEL FAX CELL EMAIL contact@spryplumbing.com D MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY gartyi v MA DATE II I I i ZT'- GI G�3 PERMIT# �d JOBSITE ADDRESS Cl CaSk LA OWNER'S NAME O C Coy ilk rtvt S-1 gn OWNER ADDRESS TEL Q"S7-ad O-sl 7 7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:,a PLANS SUBMITTED: YES❑ NO❑ FIXTURES-1 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/OIL/SAND 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 I a. ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I a 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 c pli ce with all Pertinent provision of the Massachusetts State Plumbing1lu/ Code and Chapter 142 of the General Laws. PLUMBER'S NAME 6..-V it C- S Pr froLICENSE# I SR tl SIGNAawriqtr TURE ~it_ MP[9 JP❑ CORPORATION❑# PARTNERSHIP❑# LLC #3Ss'P COMPANY NAME S4rb �ur•Nin.1 �,�� < <f L ADDRESS 9 a ,01/4)Sher«( Ual o CITY K a c-Lta". STATE h.A ZIP n a.3'I p TEL 1 er 0,177 FAX CELL `7 k 704- 6 bS 1 EMAIL Cur•-i-at G+ e Spr 2 r\v"'"4J`'�� . L©