HomeMy WebLinkAboutBLDP-22-003186 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 12/6/21 PERMIT# BLDP-22-003186
p JOBSITE ADDRESS 29 FOREST GATE VILLAGE OWNERS NAME Lynn Gorey
P OWNER ADDRESS 29 FOREST GATE YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENTS.0 PLANS SUBMITTED: YES NO❑
FIXTURFS 1 FLOORS—. BSM 1 2 3 4 9 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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 1
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
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 El NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND El
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 Dean Farnham LICENSE f8203 SIGNATURE
MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME DEAN P FARNHAM ADDRESS 8 WILLOW WAY
CITY SOUTH DENNIS STATE MA ZIP 026603060 TEL
FAX CELL I EMAIL Ideanfarnham56@gmail.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ID El
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
E=—7
CITY �r c� 4 'Cil i MA DATE /A ' / PERMIT# Z 3/
JOBSITE ADDRESS 2 �C> ✓ r'S; 6 S r C OWNER'S NAME C)//1"/ C /r
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ : RESIDENTIAL _"-
PRINT - .Y Y
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 r PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR— BSM 1 2 3 4 5 [Llt C -72O21 B 9 10 11 12 13 14
BATHTUB i �4....
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 1 MOP SINK
TOILET
URINAL
i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
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 [n/ 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
L'‘1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accirate to the best of my knowledge
nce EiP
and that all plumbing work and installations performed under the permit issued for this application will be in mpliae?tis-nt provi jon-of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURE
MP ❑ JP ❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME'—�C �%l �',,,Lrc ADDRESS �z/� l��_ ✓may
CITY 1 .-7`r STATE `7 (i ZIP 0)C60 TEL
FAX CELL/A l!�' /2 EMAIL de S/t �; 1�ic-� 6 �'rt <. ! L
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
1