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HomeMy WebLinkAboutBLDP-23-005248 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4.1.76,6,77.e CITY YARMOUTH MA DATE 3/23/23 PERMIT# BLDP-23-005248 JOBSITE ADDRESS 141 HIGHBANK R �pMet S /7/74 OWNER'S NAME HIGHBANK PROPERTIES INC P OWNER ADDRESS C/O BLACK ALEX 141 HIGHBANK RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0 FIXTURES .t FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 2 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 2 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 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 0 NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 'James Connolly I LICENSEItb135 I SIGNATURE MP © JP ❑ CORPORATION ❑# ' J PARTNERSHIP ❑# I ' LLC ❑# ' COMPANY NAME 'James M Connolly I ADDRESS 192 DEXTER RD CITY 'MARION ' STATE IMA I ZIP 1027381237 FAX ' I CELL ' I TEL ' ' EMAIL 1 4-4 se MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a 1 F= CITY MA DATE .2 `7 ' iy 'vG EN��T ENT : PER,�� 23 .005ZW( JLOBSITE e RDRRSS / /¢. OWNER'S NAME OWNER ADDRESS 6 5�5 �?y / �i��7�:�1 / TEL `7 "SV TYPE OR OCCUPANCY TYPE x PRINT COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�] CLEARLY NEW:yi RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR-+ BSM 1 2 3 4 BATHTUB 5 6 7 8 9 10 11 12 13 14 I 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 • FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN • SHOWER STALL SERVICE/MOP SINK TOILET - 1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE I have a current liability insurance policy or its substantial eq va ent which meets the requirements of MGL Ch. 142. YES IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW NO ❑ LIABILITY INSURANCE POLICY: OTHER TYPE OF INDEMNITY El BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not Ve the insurance coverage required by Chapter 142 of t Massachusetts General Laws, and that my signature on this permit application waives this requirement. he SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER L',i I hereby certify that all of the details and information I have submitted or entered regarding this application are true a AGENT and that all plumbing work and installations performed under the permit issued for this application will be in cprr�p Massachusetts State Plumbing Code and Chapter 142 of the General Laws. nd accurate to the best of my knowledge Hance with all Pertinent provision of the PLUMBER'S NAME LICENSE# f/13 s< SI URE MP JP 0 CORPORATION{f#3yl.�I PARTNERSHIP❑.# COMPANY NAME ut �' k � LLC❑ ADDRESS h 1" /17 .� •,Cry +� �"�.�Z�,,- � � C �r(.�„1 CITY STATE yl ZIP S '� FAX TEL �C�� 5 , ��� CELL EMAIL