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HomeMy WebLinkAboutBLDP-23-001926 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,r ' w, et CITY YARMOUTH MA DATE 10/11/22 PERMIT# BLDP-23-001926 ti JOBSITE ADDRESS 32 GENERAL HOLWAY RD OWNERS NAME WILLIAMSON THOMAS J OWNER ADDRESS WILLIAMSON MARY E 32 GEN HOLWAY RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES z FLOORS--..4 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 2 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 'Zachary Lucas LICENSE 1i6865 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME MID CAPE MECHANICAL ADDRESS 300 Queeen Anne Rd. CITY (Harwich I STATE MA ZIP 102645 I TEL FAX I I CELL I I EMAIL Imidcapemechanical@gmail.com MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK s e_ : / t CI1 tl v"7 G V'f Lt MA DATE 16/' ( 2-Z PERMIT# l. .. T 1 •1►�22E D''ESS g 2 6 e n e c c 1 Coo I �aY 12 OWNER'S NAME -To a— 5,__ �u�l�ve i���d � ry D. SS TEL qs8 2/02. FAX By _ TYPE OR • : " TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er - PRINT CLEARLY NEW:0 RENOVATION:2/ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO®' FIXTURES-1 FLOOR-+ BSM 1 2 3 4 5 6 7 8' 9 10 11 12 BATHTUB 13 14 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) i KITCHEN SINK LAVATORY at ROOF DRAIN _ • , SHOWER STALL. SERVICE/MOP SINK TOILET URINAL I 1 . WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER J INSURANCE COV I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[VNO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT El Lk! 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 ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME 2 ( L e aS LICENSE#M i b ac,5 SIGNATURE MP Ef JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0# COMPANY NAME P't i`a Ca Me_clAQ vl ;cQ 1 ADDRESS p !3 k )I) 3 a CITY Co, (l tu+tl g w( STATE I"4 ZIP 0.2 4,6 q v 2fc TEL E� 1'277 FAX CELL 5 29,4 927? EMAIL 3 I G . Csyi