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HomeMy WebLinkAboutBLDP-23-002441 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK M et CITY YARMOUTH MA DATE 11/3/22 PERMIT# BLDP-23-002441 kr tr _, JOBSITE ADDRESS 7 DUNSTER PATH OWNER'S NAME LOUGHLIN KAREN B P OWNER ADDRESS HALDE NANCY A 7 DUNSTER PATH WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 1 LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 1 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❑ 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 Gregory Selfe LICENSE 26714 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME GREGORY A SELFE ADDRESS 41 SPRINGER LN 41 SPRINGER LN CITY (WEST YARMOUTH STATE MA ZIP 1026734930 TEL FAX CELL EMAIL selfegreg@yahoo.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK g CITY yl4RMNh , MA DATE 11-3- PERMIT# 23- 721411 JOBSITE ADDRESS -7 DL,Y 5IC.0 PAN OWNER'S NAME Lo-6 � OWNER ADDRESS v^S l«% TEICSoe) r•k 76d, FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 21 PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 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 / ROOF DRAIN SHOWER STALL • SERVICE I MOP SINK TOILET / URINAL . j 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 0 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT Lt 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 NAMEaEo#sr SC({t LICENSE# 967'4 . SIGNATURE MP❑ JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC❑# D3J'4 COMPANY NAME G41.6,01CAr St(Fc S[e"K C ADDRESS qI Slag ^itA- LRr►C CITY YitirnD".4. STATE WA ZIP 04)4 `73 TEL FAX CELLCcoQ)l1$-I 43'Y EMAIL (L(Fr$fe f yaks LO�^