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HomeMy WebLinkAboutBLDP-23-003988 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK k. I I rs CITY YARMOUTH JOBSITE ADDRESS 22 WHITES PATH MA DATE 1/20/23 PERMIT# BLDP-23-003988 OWNER'S NAME DAVENPORT DEWITT TR P OWNER ADDRESS DAVENPORT REALTY TRUST 20 NORTH MAIN ST SOUTH YARMOUTH,MA TEL 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:El PLANS SUBMITTED: YES NO❑ FIXTURES _1 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 DRAIN SHOWER STALL SERVICE/MOP SINK 1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING OTHER 3 OTHER DESCRIPTION:sillcocks 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 0 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 Troy Gilbert LICENSE 16573 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME COASTAL MECHANICAL ADDRESS 21 L Fruean Ave CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL katherine@coastalphc.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `1°�- CITY Yarmouth gt4 MA DATE i ig /Z023 - PERMIT#2' ^ 3cti $8 JOBSITE ADDRESS 22 Whites Path OWNER'S NAME 22 Whites Path LLC OWNER ADDRESS 21 L Fruean Ave S. Yarmouth MA 02664 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:IV REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR—, 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 SHOWER STALL SERVICE/MOP SINK 1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER Exterior Silcock 3 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES V 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 CHECK ONE ONLY; OWNER ❑ 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 Troy J Gilbert LICENSE# 13573 TURF /���TURE MP' JP❑ CORPORATION❑# PARTNERSHIP❑# LLC i2c# 4350 COMPANY NAME Coastal Mechanical ADDRESS 21 L Fruean Ave CITY S Yarmouth STATE MA ZIP 07S64 TEL 508-737-8747 FAX CELL EMAIL KatherineaCoastalphc.corn