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Home My WebLink AboutBLDP-22-004098 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u >f-. CITY YARMOUTH MA DATE 1/25/22 PERMIT# BLDP-22-004098 JOBSITE ADDRESS 37 MIDSTREAM DR OWNER'S NAME GARDINER ROBERT C P OWNER ADDRESS GARDINER THERESA D 111 HAVILAND ST QUINCY,MA 02170 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL CI PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 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 El 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 Gregory Selfe LICENSE 26714 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME GREGORY A SELFE ADDRESS 41 SPRINGER LN CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL FAX CELL EMAIL • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `,_)_{� CITYYA"V°j-C\ MA DATE �-a�t�aa- PERMIT# Z �" Lt b`i Y JOBSITE ADDRESS -?, al 1 1)S hc fA yn Tp K kVC OWNERS NAME 44KID r N e4. POWNER ADDRESS 3 Yn . oS`--ReA m pe k ve TEL(503)6 ga'-'Y 78 D. FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIAL[ig CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 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/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / `y__ LAVATORY • ROOF DRAIN I SHOWER STALL SERVICE/MOP SINEr—K' TOILET I URINAL J,� (b { 2,y WASHING MACHINE CONNECTION G WATER HEATER ALL TYPES iLu irvzjtci " WATER PIPINGkl ti9=iV7 OTHER — — - --- 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 56 OTHER TYPE OF INDEMNITY ❑ BOND i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the s Massachusetts General Laws, and that my signature on this permit application waives this requirement. T � SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I.i 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. g PLUMBERS NAME 6fEen9'Y 5-tire LICENSE# N-7/Y . IGNATURE MP ❑ JP® CORPORATION ❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME Gr-r ory S )rc Pfcros,r4.Sc'ev, e.e. ADDRESS LIC SWAN ei.e L./P.< CITY GO - )/A( n10 ` STATE MA- ZIP 03-6-7 3 TEL�So� «l3 V FAX CEL(So$).)-7V-4 43 Y sQ r EMAIL Ce ri, e yil,_F„�,, Ci 3 .1