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HomeMy WebLinkAboutBLDP-23-002769 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 11/17/22 PERMIT# BLDP-23-002769 JOBSITE ADDRESS 30 MOSS RD OWNERS NAME Margy Simpson P OWNER ADDRESS 02493 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 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 El 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❑ OWNERS 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. PLUMBERS NAME Thomas Bulger LICENSE 1;0099 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME THOMAS P BULGER ADDRESS 10 PIPER ST CITY IQUINCY l STATE MA ZIP 021696428 TEL FAX 1 I CELL EMAIL justin@longfellowdb.com I w- —., E DMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK MA DATE • 22- PERMIT# NO 2O22JOB ITE ADDRESS [.L' I11()S` I L OWNER'S NAME I), C I Y1 r'.ii`.DING PARTr ERADDRESS !MSS 2L TEL 30 '516 3 FAX -E OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW:EY RENOVATION:®` 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 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 I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK — LAVATORY \ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL ' WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES WATER PIPING OTHER d � 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 cMassachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 rl • 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 -rh am4-s k 81/t ., LICENSE# /009 SIGN RE MP 0 JP❑ CORPORATION Ed PARTNERSHIP❑# LLC❑# COMPANY NAME Orlft 1101-1/4/ Desjr1 BU) ) ADDRESS 3to 7 Mai ai n CITY `m0LI+/I STATE-01 A ZIP odS27 TEL '7'74 - FAX CELL Lel / A 966 EMAIL 1DYV1bUI 'IY-2- 9f72t//" 60.