BLDP-22-001683 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
k CITY YARMOUTH
MA DATE 9/23/21 PERMIT# BLDP-22-001683
tIlfr% JOBSITE ADDRESS 14 SHANNON CT OWNER'S NAME ROBERTS WILLIAM R
p OWNER ADDRESS ROBERTS ELIZABETH ANN M 115 CHILSON RD WILBRAHAM,MA 01095-1225 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION 1
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 El NO
El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El 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 Ross Halket LICENSE 34296 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 169 Morgan St
CITY Holyoke STATE MA ZIP 01040 TEL
FAX CELL EMAIL rhalket@grodsky.com
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i/ce-n•:E-14 GI L OP- la— .JO
MA ^GhU3ETTE UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY
=1=E= MA DATE /Z� 2d Z l PERMIT# 1 ?ale.b U Lo
JOBSITE ADDRESS /1 .gto Qw (eat; OWNER'S NAME /r- / l.✓=
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OWNER ADDRESS /2/�digA4( Deit4f &Lai) i TEL 3 r-Si a FAX/24
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:al REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO le
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE MI
DEDICATED SPECIAL WASTE SYSTEM MO
DEDICATED GAS/OIL/SAND SYSTEMMN
DEDICATED GREASE SYSTEM _ —
DEDICATED GRAY WATER SYSTEM -
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER tl' � - � _ 111
DRINKING FOUNTAIN
FOOD DISPOSER —
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK ,•
I LAVATORY ✓
ROOF DRAIN
SHOWER STALL
I SERVICE/MOP SINK
TOILET _
URINAL
I WASHING MACHINE CONNECTION +"
WATER HEATER ALL TYPES
•
WATER PIPING ✓
OTHER ., �,a
V
INSU
NCE COVERAGE:
VI 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
CI
th
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND
OWNER'S I E is- •• 1 I m aware that the licens E]o have th Mass setts _ e insurance coverage required by Chapter 142 of the
e on this permit application waives this requirement.
P �ATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT ❑
L I hereby certify t : ..f the details and information I have submitted or entered regarding this applic. ':
and that all plumbing work and installations performed under the permit issued for this applicatio , ill be i -.mpli n e Id all rti en ovision of the
Massachusetts State Plumbingf Code and Chapter 142 of the General Laws, pp ue and accura he best of my knowledge
PLUMBER'S NAME koss . 14AL.Ker — \O
LICENSE#.3429 6 S GNATURE
MP❑ JP 54CORPORATION ❑# PARTNERSHIP I.
•COMPANY NAME LLC 0#
ADDRESS_ I �(( �Y4N
CITY �pl.t_,�_; A�
STATE _ ZIP Qi Ogp TEL
FAX v
CELIet31Z.�{ _p�2 EMAIL
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