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HomeMy WebLinkAboutBLDP-23-003482 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _(~ v CITY YARMOUTH MA DATE I12/23/22 PERMIT# BLDP-23-003482 JOBSITE ADDRESS 48 GRANDVIEW DR OWNER'S NAME POLLEY ELAINE C TR OWNER ADDRESS THE ELAINE C POLLEY FAMILY TRUST 48 GRANDVIEW DR SOUTH YARMOUTH, TEL MA 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES El 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/OIL/SAND 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 ROOF ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL _WASHING MACHINE CONNECTION 1 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. PLUMBERS NAME (Chris Poire LICENS4#3901 SIGNATURE MP JP CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I I ❑ © I COMPANY NAME I ADDRESS 137 Calvin Drive CITY (Dennis I STATE IMa I ZIP 102638 I TEL I FAX CELL I7748366461 EMAIL Imcplumber@gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =7— ' CITY ✓✓\,0.CY`nOy MA DATE I a' aL:a.- PERMIT# JOBSITE ADDRESS ` c3 CO\C-aie' e J Or OWNER'S NAME C. t i Pi2-WY Pt)Ile)/ P OWNER ADDRESS 7 c— TEL 1 2a2FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL E PRINT CLEARLY NEW:Dl RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES 7. FLOOR-' BSM 1 2 3 4 5 6 7 6' 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN _ _ INTERCEPTOR(INTERIOR) KITCHEN SINK _ ^i LAVATORY ROOF DRAIN 11 : C F ®= E SHOWER STALL __ _ SERVICE I MOP SINK [ DEC ' 2 1 TOILET URINAL L_.-- WASHING MACHINE CONNECTION BUt. L) NG EPARTMETT ! WATER HEATER ALL TYPES +� l --- WATER PIPING t/ OTHER INSURANCE COVERAGE: �' I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑ IF YOU CHECKED YES,PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY [ 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 Mas ch etts General Laws,and that my signature on this permit application waives this requirement. fir_ CHECK ONE ONLY: OWNER 0 AGENT E(.- Z SIGNATURE R OR AGENT L'I I hereby certify that all of the d ails 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 corn ' nce with all Pertinent r 'ertwft$ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ell 5 p;re LICENSE# 1-33101 RE MP 0 JP I] CORPORATION 0# PARTNERSHIP❑.# LLC D'# COMPANY NAME ?Q. ' ? 14 (--, ADDRESS a -\^-4 T •-k CITY lirye►/1Y1 'f STATE//le4 ZIP 0)--c. 1 TEL FAX CELL 77V 83�o �t(C/ EMAIL e- p( b€Y C3° 0,1 I • Likt ce -1 c t 4 .