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HomeMy WebLinkAboutBLDP-23-001493 I t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 9/20/22 PERMIT# BLDP-23-001493 tl � JOBSITE ADDRESS 915 WEST YARMOUTH RD OWNER'S NAME torn connoly P OWNER ADDRESS 915 WEST YARMOUTH RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURES • 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 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❑ 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 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 Leon Hall LICENSE W82 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME LEON R HALL ADDRESS 77 Hazel Ln CITY Brewster STATE MA ZIP 026311729 TEL FAX CELL EMAIL Inone I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK ':(:.---- j,, CITY �1��I�UT"/`7C MA DATE /y/ PERMIT# Z 3 - / t-f 91 JOBSITE ADDRESS ?/ w,- Y rha'rnr4 Qom- YR OWNER'S NAME 1D C'cw.rvaic�Y POWNER ADDRESS .5e /F TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL®2°' PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:2 PLANS SUBMITTED: YES 0 NO®' FIXTURES.7 FLOOR-* BSM 1 2 3 4 5 6 7 B' 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM DISHWASHER - DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN , .CE e t D INTERCEPTOR(INTERIOR)KITCHEN SINK LAVATORY ' • t � a o- ' • ROOF DRAIN , SHOWER STALL x uILuIN verAH1 ICr\I j SERVICE/MOP SINK > - - --- TOILET x URINAL I 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 0 NO Ea' IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY 0 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 i Massac eneral Laws,and my signature on 's permit application waives this requirement. r CHECK ONE ONLY: OWNER I'' AGENT 0 SIGNATURE OF OWNER OR AGENT k:t 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 r,,perovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /� ���y2 PLUMBER'S NAME LICENSE# „S77gg. SIGNATURE MP a JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME ADDRESS 7> /7"Az'i. �, ,yam CITY /3/(1 l,- STATE /li//. ZIP C?of a4/ TEL 77 -`v.A8- g FAX CELL EMAIL • CV4 J29 2