HomeMy WebLinkAboutBLDP-23-003181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 12/8/22 PERMIT# BLDP-23-003181
JOBSITE ADDRESS - ; �,� , OWNERS NAME PAMPOSH USA INC
P OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:❑ 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 1
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 3 3
ROOF DRAIN
SHOWER STALL 1 3
SERVICE/MOP SINK
TOILET 2 3
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER 2
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 0 OTHER TYPE OF INDEMNITY❑ BOND 0
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 Mccarthy LICENSE St016 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME WILLIAM E MCCARTHY ADDRESS 1042 N Main St
CITY Raynham STATE MA ZIP 027671744 TEL
FAX CELL EMAIL bwaterplumbing@yahoo.com
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_ ` � = MA DATE / PERMIT# 2-3 5 i i
JbB51TE DD ESS 7 0c0 1 `1 > P- S I OWNER'S NAME. Awt \ i . (-/S0 \"L. C
Liir 0 8C4174 D ESS TEL FAX
B.By
YPE E"4=00 \ TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL :
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO ,
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 B' 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE I
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 I AREA DRAIN -
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 3• _ ry .
ROOF DRAIN
SHOWER STALL I
SERVICE/MOP SINK
TOILET Z. 3
URINAL — )--'
. j WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES J _
WATER PIPING i
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESV NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
z Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
�I 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 c i ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME l ,\\\AWN Pk C.C-r34.1L`I LICENSE# (`/e f `SIGNATURE
—
MP�- JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME '‘`Z' "SE'Q- t''2' l b 11 ADDRESS Art 2, OA- :t1 ill vo w" j I
CITY ‘Q ..0.- L STATE rik l - ZIP 0-2?t ,-7 TEL
FAX CELL --Ckr.YL'( '.?13 EMAIL 27 ttiviig PLx I ( yak-k-- Chi