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HomeMy WebLinkAboutBLDP-22-007073 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK cp CITY YARMOUTH MA DATE 6/7/22 PERMIT# BLDP-22-007073 �' ' JOBSITE ADDRESS 33 CRANBERRY LN OWNER'S NAME MUSE WILLIAM C P OWNER ADDRESS MUSE MARGARET A 33 CRANBERRY LANE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: 0 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION:outdoor shower 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 'William Woods LICENSE#1887 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME WILLIAM T WOODS ADDRESS PO BOX 702 CITY W BARNSTABLE STATE MA ZIP 026680702 TEL FAX CELL ' EMAIL adadsl0@comcast.net MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `��— �b. *04 MA DATE (1/i7 O7-a, PERMIT# 7U=1=�=� CITY '2Z— 73 JOBSITE ADDRESS 3? C l ( 4, OWNERS NAME A.vece POWNER ADDRESS 33 CrP_MiiP 2. . TEL FAX TYPE OR OCCUPANCY PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®/ PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES Ill NO❑ FIXTURES 1 FLOOR-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/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 I RECEIVED SHOWER STALL SERVICE/MOP SINK JUN 03 2022 1 - TOILET URINAL _ - i WASHING MACHINE CONNECTION i t3UilurnGDE-PA4TMEIV'r r— WATER HEATER ALL TYPES — ---- e3-- WATER PIPING OTHER AI(-& SAi-i/IA/ / iI INSURANCE COVERAGE: � � I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Cl/NO NO 0 IF YOU CHECKED YES,PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY 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 l Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT �1 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 knowledgf and that all plumbing work and installations performed under the permit issued for this application will be in c mpliance with all Pertinent rovi ' of the Massachusetts State Plumbing Code a d Chapi r 142 of the General Laws. PLUMBER'S NAME 6 G I 4/ "-5 LICENSE#C` 7 SIGNATURE MP L!2 JP❑ ORPORATION[ PARTNERSHIP Ell LLC❑# o COMPANY NAME /[�J 13 S '� 6 ADDRESS A 40 C "):4:2"— CITY�d - �� STATE JAVF ZIP A2-6'f 'U TEL 6-Pr (U.21&5 FAX Jjp01- Lt d'"c3 CELL3 67<7 6 EMAIL AWS /0 a ,p/ ` 66 L`-t