HomeMy WebLinkAboutBLDP-21-006740 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
77 CITY YARMOUTH MA DATE 5/20/21 PERMIT# BLDP-21-006740
(-f JOBSITE ADDRESS 142 OCEAN AVE OWNERS NAME LUSH ALLEN M TRS
p OWNER ADDRESS LUSH GAIL A TRS 13 MAYFAIR DR BOXBOROUGH,MA 01719-1838 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURES 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 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK _
TOILET 1 _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER _
WATER PIPING
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 El
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 Brian Powderly LICENSE tQ026 SIGNATURE
MP ❑i JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Powderly&Sons Plumbing&Htg ADDRESS PO BOX 235
CITY Nutting Lake STATE MA ZIP 01865 TEL
FAX CELL EMAIL