HomeMy WebLinkAboutBLDP-18-005134 R.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
::,e�10—
� " CITY WEST YARMOUTH MA DATE 4/9/18 PERMIT# &P/-`-i5- .5"54
JOBSITE ADDRESS 131 LEWIS RD OWNER'S NAME JEFF BELLINO
POWNER ADDRESS SAME TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL fl EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:El REPLACEMENT:E] PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1, Ii 1,
CROSS CONNECTION DEVICE i ) '
DEDICATED SPECIAL WASTE SYSTEM L L L
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM I i. :
DEDICATED GRAY WATER SYSTEM d , . I li
DEDICATED WATER RECYCLE SYSTEM 1 i
DISHWASHER
DRINKING FOUNTAIN i
FOOD DISPOSER
i. '
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I ,,rIli If 1 i. ti [.
KITCHEN SINK „w 'j[I.,,,,.._ . C _ :
LAVATORY i� ;
ROOF DRAIN € ., —
SHOWER STALL : ( I ( j
SERVICE/MOP SINK � ;._... rod,,
TOILET
URINAL 1 [ f • ''�1
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1 1"'"''''''
WATER PIPING . .I it
OTHER = I t i I
i ;I 1 1 . 1
l i
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 171 OTHER TYPE OF INDEMNITY ii BOND D
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.
CH''K ONE ONLY: OWNER AGENT El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applic. onu: true and urate to the st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will se in ,mpli;nc with all Pertinent p ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Richard J.Whiteside LICENSE# 15850 L Jill
11/ V SIG ATU
MP El JP II CORPORATIOND# 3969 PARTNERSHIP[,# LLC,, ,f#
COMPANY NAME Murphy Services Inc ADDRESS 34 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-760-1660
FAX 508-760-1670 CELL EMAIL cshea@callmurphys.com // ekarukas@callmurphys.com
ag,