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HomeMy WebLinkAboutBLDP-23-003133 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK +� CITY YARMOUTH MA DATE 12/7/22 PERMIT# BLDP-23-003133 r JOBSITE ADDRESS 1777 WEST YARMOUTH RD OWNER'S NAME IDEARDEN LAURIE A P OWNER ADDRESS 777 WEST YARMOUTH RD YARMOUTH PORT,MA 02675 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURES z FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION: ice maker 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 'Michael Mcbride I LICENSEI1a9681 SIGNATURE MP ❑ JP © CORPORATION ❑# I I PARTNERSHIP ❑# ' I LLC ❑# COMPANY NAME IMICHAEL R MCBRIDE I ADDRESS 19 Rustic Drive CITY (West Yarmouth I STATE IMA I ZIP 102673 ' TEL ' J FAX I I CELL I I EMAIL Istinger.mcbride@gmail.com . .., _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :`� r CITY MA DATEAr "` Z PERMIT# al — 3/.33 JOBSITE ADDRESS P .55 OWNER'S NAME Srz r� �, OWNER ADDRESS r _ Q�✓ / R_____51ta:111LV7( TYPE OR OCCUPANCY TYPE FAX PRINT COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 1.. CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Eij PLANS SUBMITTED: YES❑ NO[e FIXTURES 1 FLOOR-+ BSM 1 BATHTUB 2 3 4 5 6 7 8 9 10 11 12 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 KITCHEN SINK LAVATORY ROOF DRAIN '� SHOWER STALL V'��A7_�ra imirmil SERVICE/MOP SINK �� TOILET ■ ! faMMINIM URINAL .. ENNIIIMINNMEMII WASHING MACHINE CONNECTION WATER HEATER ALL TYPES • . OTHER .�•�L�'�,e; w Al 14 J/ I have a current liability insurance policy or its substantial equivalent INSURANCE which meets the requirements of MGL Ch.142. YES IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW NO UABIUTY INSURANCE POUCY h'' OTHER TYPE OF INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b j Massachusetts General Laws,and that my signature on this permit application waives this requirement. y Chapter 142 of the SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 L:1 I hereby certify that all of the details and information I have submitted or entered regarding this application an; and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision Massachusetts State Plumbing Code and Chapter 142 of the General Laws, true and accurate to the best of my knowledge PLUMBER'S NAME �j r^/ p vision of the l f `� I LICENSE# 17 / �—"— MP❑ • JP SIGNATURE ` CORP RATION # COMPANY NAME (`/ 0 PARTNERSHIP❑# LLC❑# C -_ STATE ADDRESS 4 CITY FAX =="` ZIP a CELL �,/ TEL �J1 Z 7_i_ Tia0 L ? I EMAIL _ - i . Ii 1 I