HomeMy WebLinkAboutBLDP-23-03483 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I MA DATE 112/23/22
CITY 'YARMOUTH
I PERMIT# BLDP-23-003483
k‘°117-17-' JOBSITE ADDRESS 118 SCALLOP RD
OWNER'S NAME'MORRISON JEFFRY M
P OWNER ADDRESS 'POWERS MARY E 1 FOREST CIR COHASSET,MA 02025
'TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑
PRINT RESIDENTIAL ❑
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑
FIXTURFS t FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1 2
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
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❑ 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 Gary Jones
LICENS *•:90
MP � JP ❑ SIGNATURE
CORPORATION ❑# PARTNERSHIP ❑#
� LLC ❑#
COMPANY NAME
Gc Jones Plumbing&Heating ADDRESS 12, Yeoman Drive
CITY West Yarmouth STATE MA
ZIP 026731432 TEL
FAX CELL 5085092725
EMAIL