HomeMy WebLinkAboutBLDP-23-005344 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/29/23 PERMIT# BLDP-23-005344
--,/ JOBSITE ADDRESS 134 ROUTE 6A OWNER'S NAME GOLDEN JALAPENOS LLC
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P OWNER ADDRESS 134 ROUTE 6A YARMOUTH PORT,MA 026750000 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
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING 1
OTHER 3
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 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 Dunphy LICENSE 31699 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME WILLIAM M DUNPHY ADDRESS 152 PARK ST UNIT 1
CITY N ATTLEBORO STATE MA ZIP 027601213 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE El El
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE✓✓ADDRESS ,'31- S'T 1 -� -- �l�OWNERS NAMEUeC&-K. k .5?pc-gkLl la
POWNER ADDRESS/PI ,C -4f ' 6 4 Ci rk r-t-^--- '::'TEl. 93)—G 6°-.77-.24(X
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION 1 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
FIXTURES 7 FLOOR--s 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 7
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER .
DRINKING FOUNTAIN —,FOOD DISPOSER -.FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) -
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET E V E I]
j URINAL
. j WASHING MACHINE CONNECTION k
I WATER HEATER ALL TYPES 3
WATER PIPING 1
OTHER BJILDl G DE'ARTMENT I
iY4'i o is'In K f
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
1' 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 co lance with all Pertipent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /16
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PLUMBER'S NAME lt3,'8 9 u 11,E hid" LICENSE#)�G IGN RE
MP❑ JP l CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAMEQU / - PJur1`�' ADDRESS 7 �C -- I
CITY//e&r i414 f f.1-> iL,'i--1- ' *ATE iV\' - ZIP G.-4- 7 1 TEL509: '02I -IFY6
FAX CELL EMAIL 6 f— 52 /91 6.6 FL-
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