HomeMy WebLinkAboutBLDP-22-004111 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ter, CITY YARMOUTH MA DATE 1/25122 PERMIT# BLDP-22-004111
V. JOBSITE ADDRESS 46 KATES PATH VILLAGE OWNER'S NAME DEUTSCH MICHAEL J
P OWNER ADDRESS 'DEUTSCH LAURA F 47 EAGLE DR SHARON,MA 02067 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES NO❑
FIXTURFS • 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 2
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 2
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 El NO El
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 brian hibbard I LICENSf'ff1977 SIGNATURE
MP El JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS po box 429
CITY south dennis STATE MA ZIP 02660 TEL 5083982228
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑
FEES$ PERMIT#
PLAN REVIEW NOTES