HomeMy WebLinkAboutBLDP-23-002090 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Ci-&. CITY YARMOUTH MA DATE 10/19/22 PERMIT# BLDP-23-002090
1 JOBSITE ADDRESS 92 ROUTE 6A OWNER'S NAME HICKEY MALCOLM K
P OWNER ADDRESS C/O VILLAGE INN CAPE COD LLC 92 ROUTE 6A YARMOUTH PORT,MA 02675 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
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
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 Richard Bartels LICENSE V1845 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME RICHARD D BARTELS ADDRESS 7 PLEASANT PARK CIR
CITY HARWICH STATE MA ZIP 026452017 TEL
FAX CELL EMAIL bartelspha@comcast.net
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE El ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
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- 1 SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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-,_jamtri- CITY y�p�/� MA DATE //'-/'- -2 PERMIT#
VA 17Z. s"�� IT ACDRESS C� V '
�A . l /—� OWNER'S NAME� r/l�/1/�/�
B U!L r r'�'AWN�AD jRESS
r3 y- _-. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL ---
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:&--- PLANS SUBMITTED: YES❑ NO174-
FIXTURES 1 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 - L - —___,_
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
/LAVATORY _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK •
TOILET
j URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
I
i
INSUANCE COVERAGE:I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES[ 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY C. 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 II] 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
and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / knowledge
PLUMBER'S NAME /(IC .D .�. it7-4-Gf 6 �A�/t
LICENSE# l/�lS" SIGNATURE
MP P''"---JP❑ CORPORATION El# PARTNERSHIP❑.# LLC #
COMPANY NAME��/L�CJ`- ❑
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CITY GG/G�
STATE, ' ZIP L?____kj--- TELL 3—J
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