HomeMy WebLinkAboutBLDP-21-004323 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 2/1/21 PERMIT# BLDP-21-004323
JOBSITE ADDRESS 20 FREEMAN RD
OWNER'S NAME VOGT DEBORAH
P OWNER ADDRESS 20 FREEMAN ROAD YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
FIXTURES z 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 1
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER 1
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❑
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 (Thomas Flynn J LICENSEI34167
SIGNATURE
MP 0 JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I ❑# I
LLC
COMPANY NAME (Flynns plumbing I ADDRESS 1118 wayside dr
CITY Iharwich I STATE IMA I ZIP 102645 ( TEL
FAX 1 I CELL 15082413438 1 EMAIL