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HomeMy WebLinkAboutBLDP-23-001578 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY (YARMOUTH MA DATE 19/26/22 PERMIT# BLDP-23-001578 JOBSITE ADDRESS 146 BOB-0-LINK LN OWNER'S NAME IPINKNEY SARAH P OWNER ADDRESS IPINKNEY JACOB 56 WEBBERS PATH WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES z 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 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❑ 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 (Ryan White I LICENSE116068 J SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# COMPANY NAME 'White plumbing and heating I ADDRESS IPO box 425 CITY (Harwich I STATE IMA I ZIP 102645 I TEL 15082467375 FAX I I CELL (5082467375 I EMAIL I