HomeMy WebLinkAboutBLDP-21-005108 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/9/21 PERMIT# BLDP-21-005108
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JOBSITE ADDRESS 22 VINEYARD ST OWNER'S NAME JAMES OBRIEN
P OWNER ADDRESS 191 HURON AVE CAMBRIDGE,MA 02138-1325 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES 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 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER 1
WATER PIPING
OTHER 1
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 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 Michael Mcbride LICENSE 1'8681 SIGNATURE
MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC El#
COMPANY NAME MICHAEL R MCBRIDE ADDRESS 9 Rustic Drive
CITY West Yarmouth STATE MA ZIP 02673 TEL
FAX CELL EMAIL stinger.mcbride@gmail.com
se
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT 0 ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
//0
MASSACHUSETTS UNIFORM APPLICATION FOR A ER T TO PERFORM PLUMBING WORK
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CITY MA DATE PERMIT# T�La- Z( S O
JOBSITE ADDRESS 2,2
i\-0_ cr 11 /`e 01 R'S
OWNER ADDRESS n_D L6 S [J f/J � l x�
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Pi
PRINT
CLEARLY NEW: 7 RENOVATION:it REPLACEMENT: PLANS SUBMITTED: YESk NO ❑
FI)C URES 7 FLOOR—+ BS1v1 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
I f 1
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 1 MOP SINK
TOILET
URINAL
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. YESIA 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
it 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 and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application wi be in compliance ith all Pertinent provision of the
Massachusetts State Plumbing C de and Chapter 142 of the general Laws. it
M
PLUMBER'S NAME ! " ( ICXO LICENSE # SIGNA RE
MP 1-1 JP X, 1 y / CORPORATION ❑# PARTNERSHIP ❑#0(`o LLC ❑#
COMPANY NAMEM j-3 "(, ADDRESS (2.4) i6A-e
CITY Gt � STATE � ZIP l-67 7 TEL 7, y 7i y a
FAX CELL EMAIL - f L Cam.
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