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HomeMy WebLinkAboutBLDP-23-001341 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • fir, CITY YARMOUTH MA DATE 9/13/22 PERMIT# BLDP-23-001341 al �� JOBSITE ADDRESS 28 WEST WOODS VILLAGE OWNER'S NAME JOHNSON ALAN W SR P OWNER ADDRESS 28 WEST WOODS YARMOUTH PORT,MA 02675-1462 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL D PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ 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 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 2 1 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION:ice maker line 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 Troy Gilbert LICENSE 10573 SIGNATURE MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME COASTAL MECHANICAL ADDRESS 21 L Fruean Ave CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL katherine@coastalphc.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '°r— cnTY Yarmouth MA DATE 09/08/2022 PERMIT# 2.3` /3 49( JOBSITEADDRESS 28 W Woods Unit 28 OWNER'S NAME DENBY BRENDA M TR OWNER ADDRESS 28 WEST WOODS VILLAGE TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:cif REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOOR-I 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 2 1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER Water Line To Fridge _ 1 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 Ad 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -7 PLUMBER'S NAME LICENSE# l TURE MPV JP❑ CORPORATION❑# PARTNERSHIP❑# Lc❑# COMPANY NAME Coastal Mechanical ADDRESS 21 L Fruean Ave cl-rn S. Yarmouth STATE MA ZIP 02664 TEL 508-737-8747 FAX CELL 508-850-6955 EMAIL Katherine@Coastalphc.com