HomeMy WebLinkAboutBLDP-21-000095 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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RI � CITY Yarmouth MA DATE 7/6/2020 PERMIT#1%��/-al-04,4`Jf
JOBSITE ADDRESS 64 Betty's Path W.Yarmouth OWNER'S NAME John&Linda Bussierre
OWNER ADDRESS J TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ] RESIDENTIAL
PRINT
CLEARLY NEW:] RENOVATION: ✓] REPLACEMENT: PLANS SUBMITTED:YES❑ NO❑
FIXTURES? 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
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1
OTHER I Bar sink 1
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.
CHECK ONE ONLY: OWNER❑ AGENT❑
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 nd accurate to a best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in nce
Sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Peter J.Hassett I LICENSE# 11682 SIGNATURE
MP❑ JP CORPORATION #1O6 PARTNERSHIP❑# LLC❑#I
COMPANY NAME. Hassett Plumbing and Heating,Inc. ADDRESS 8 Skipper Lane
CITY Yarmouth Port ]STATE MA ZIP 02675 —1 TEL 508-744-7555
FAX CELL 508-237-2175 EMAIL peterjhassett@gmail.com
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