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HomeMy WebLinkAboutBLDP-22-006640 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK cl CITY YARMOUTH MA DATE 5/17/22 PERMIT# BLDP-22-006640 JOBSITE ADDRESS 85 WIANNO RD OWNER'S NAME Jane McColl OWNER ADDRESS 85 WIANNO RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES • FLOORS--0 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 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 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Cl 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 Darrell Shedd LICENSE03 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# I LLC ❑# COMPANY NAME IDARRELL D SHEDD ADDRESS 730 TYLER ST CITY IPITTSFIELD I STATE IMA I ZIP 012014319 TEL FAX ( I CELL I I EMAIL Idshedd@sheddplumbing.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =1'= CITY /4RMWTh MA DATE '/7/1/2 2— PERMIT# 2Z— " • � �� JOBSITE ADDRESS g S /Af► 140 Rb OWNERS NAME -`I�;4IVE Alt teat, OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL kl PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑ FIXTURES- 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 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 a( NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IS1 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 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 ce wit I ertinent pr •sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME LICENSE# 81103 SIGNATURE MP$ JP❑ CORPORATION El# PARTNERSHIP❑# LLC❑# COMPANY NAME £// I2 PLuw1II/A1& ADDRESS 1 P e_Aitsthp 1.044/ ,/ CITY IV TN IAA° STATE 141 A' ZIP O26SZ TEL �.3-V4/- 4019 FAX CELL EMAIL ols/teddkslte1dplvisib►nt•(Owt