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HomeMy WebLinkAboutBLDP-23-003338 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 12/15/22 PERMIT# BLDP-23-003338 91141171 JOBSITE ADDRESS 30 MOSS RD OWNER'S NAME Margy Simpson P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES CI NO 0 FIXTURES -1 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 1 ROOF DRAIN ...SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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❑ 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 Bulger LICENSE 1;0099 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# I COMPANY NAME THOMAS P BULGER ADDRESS 10 PIPER ST CITY IQUINCY I STATE MA ZIP 1021696428 I TEL I FAX I CELL I I EMAIL Ijustin@longfellowdb.com 1 J 1 I I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK li-�" CITY ��f 4' r",th 1 MA DATE 14)3,)2 Z PERMIT# 2,3-- 3 3 • JOBSITE ADDRESS 30 1''\USS 0_61 OWNER'S NAME itAarLg'y S;/YiP-i P OWNER ADDRESS ,30 Mt SS 2d. TEL(7/7-ga.--9'30 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL g-'' PRINT CLEARLY NEW:❑ RENOVATION:a` REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ,— , CROSS CONNECTION DEVICE I ETCQ 2Q2Z DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 4gy DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) , KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL I i 1 — - , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING 1 OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicati 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 in mpliancee)/itch all P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( 10 /11 PLUMBER'S NAMElh S P/jiy1K LICENSE# /Q iqq t SIG ATURE MP JP❑ CORPORATION❑'#.09/ PARTNER HIP❑# LLC❑# COMPANY NAME / On i�>°I1 o t �C S l%r w id ADDRESS 3(0-1 j27 ,1/� Y, tt y p CITY Ffi fir D1 LH 1 STATE �/9 ZIP D 2 4v TEL l�/7- 9 - /63o FAX CELL EMAIL '72Ii 1 b/41g?Y O-5rnkji/• 22/n 1