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Home My WebLink AboutBLDP-21-004439 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/5/21 PERMIT# BLDP-21-004439 altr_t) JOBSITE ADDRESS 92 WAMPANOAG RD OWNER'S NAME HOGAN STEPHEN P OWNER ADDRESS HOGAN NANCY 109 BURROUGHS RD BRAINTREE,MA 02184 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑� PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 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 ❑ 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. 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 David McCrossin LICENSEX1694 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME DAVE THE PLUMBER ADDRESS P 0 Box 352 CITY Dennis STATE MA ZIP 02639 J TEL 5083983283 FAX CELL 5083983283 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES • Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ FEES$ PERMIT PLAN REVIEW NOTES (4 5- � r • \i\j . . c tz,,, ja 1 . . Cop .S0 (N.- . - . • . . . .. - • •_. MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM.PLUMBING WORK - i !l. tiro = CITY a.T Ire it } 1MADATELJc/)LJPERLIrT# L ZI `��L/3 „ r JOBSITE ADDRESS 1 /;�,ina, A 0 0 a i j OWNER'S NAME v e r : ,c,,,,,,1 l e y: I • • 4-1 OWNER ADDRESS ,r .�.) J TEL 1 7 S 3k 7.. IFAXI . TYPE OR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL ID • RESIDENTIAL04 • �`' 7 3 PRINT CLEARLY NEW: ID • RENOVATION:{J REPLACEMENTS : PLANS SUBMITTED: YES Q NOD FXTURES 1. FLOOR--+ BSM 1 2 3 4 5 6 7 - 8 9 10 11 12 13 14 • . 1 _I ...L_ . • it 1 :II 'll. II - ; • II I _ _ :I- :1_ • .i CI,ROSS CONNECTION DEVICE . 1111111 • :Ins:11.1 _ MI wins_inn ___ DEDICATED • - 1 - 1— ITEiEEiE' EJf II •1 ! III " �� OW _ ll III -�II I __ ��! a, .I :h •!I •1 ----- r G DRINKING FOUNTAIN . .011 fl li l'L IIiFII ►IIIIIIL—IiC_II IONAlt FOOD DISPOSER • 1 f_____1=1.=_IL____11_11 1 .41____=.4..:=4 ._ _ 1 __:11 _._,I____..i; .______J 70 --' IWTERCITTOR(INTERIOR) 1____ -- '_____I i —_k - n KITCHEN SINK • - __ .. i • ---__UMW. - Ii I____ 1111111111111 LAVATORY i • ._ 1._ -. . t . _ $ I if t I_ I_ __ I . _ t. t _ I Ii. - ROOF DRAIN l l i INK M _ -__ :I im, __ -- pm am SERVICE f MOP SINK _ . iI _ i ii - —- I --- I� I 1 _._II---- -- --- _li _-- --1i -- . --II .- . --•I► ---- --- .1 11 IIMI • TOILET •1 i 1' • 1 I li 1 • • • f URINAL . . . . AmIi iI I I Ii JI it. Ii il.11inli i li.iNINI.1 WASHING MACHINE CONNECTION II 1 iiiiii1i. i-- lr L'I I•. IL ii •Ii ii , WATER HEATER ALL TYPES . I 0. • t • 11 I_ I . I. Il ! I. EI I —_ _- • WATER PIPING L III 0 1 t II - Ill 0. - I • k Imam m ii OTHER - '• "-a,V e r I' 11 ` I` y I' III i. I • - I _ it i! , I II I I is� I - -- - - --- i u _ _11 , _11 .i . I_ I ( . - Ii . ilk _1 1 _ :• _ - 'mil i I i -- -- II I __ I Ii ii�ll hail l l i I: ,ii " • INSURANCE COVERAGE: I have a curient liability insurance policy or its substantial equivaleri which meets the requirements of 141GL Ch. 142. yES WNO 0 2221 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW _ • _Nv uEf Ar�.TME T ,....1 LIABILITY INSURANCE POLICY El 0ThER TYPE OF INDIIUWITY D 'BOND LI •• 1 LDl L____ - .......... OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by •Chapter 1�2 of the • • 'Massachusetts General Laws, and that my signature on this permit application waives this requirement • - • CHECK ONE ONLY: OWNER U AGENT 9 SIGNATURE OF OWNER OR AGENT • t hereby certify all of the details and informafion I have submitted or entered regarding this appIc�on are true and a. rate to the best of my ic,ow ledge • and that all plumbing work and instaliafions performed underthe permit issued for this application will be in clxnptla'n/ae with all Pertinent provision of the • Massa •iusetts State Plumbing Code and Chapter 142 of the General Laws. Z ; /� ` 'C elie, ' PLUNQE'S NAME . 1)c 1%i c C Croiiix. (LICENSE# ) 1 (...11 41 • SIGNATURE IPLI JP I - - - CORPORATION U IPARNERSHIP D# u_c[J+ - . COMPANY NAME ' - 1�., \v'�e ��I U �� Ir � - ( wss �-� L• � . � 5 � t CITY ] , r" A , j ec. k-. ,STATE fitA ZAP 0.. . Cz1 TE{ .3 � _E 7i k (3 9 .8 3 a$ 3 ( • • FAX t ( cai. BAIL o�v� CQ) C�is•v�' -�'�,,� �1�mb� -- C. G�� ' , • ID&$Rehr of Ester.'Whey ft k wry m:sale am inspect=to ado=the proves=of tha adz,erwhere the aspacor has reasa7rabie mane to believe t ac slue masts In asruaae true=a preaicrsa coralitken wrath Is=atmrp m or In r+olottan:slits aide which makes the structure err P►eraees weak dangerona or haardmat the h ope=k authorized to eater the=mare or PremissFs at rem lira:m hspea Oita pmform the dutirs troposoii bye melt, prarudee thit Esarh strsr.�an er ph:r ices be:ersrpied true ansientaks be lamented to the=pact and enemy requested. Exact:sai re or monism is unoompled.the bop=ghat far male:a reaso abk effort m hearth the owner or at m-;moon having charge err control of the s umsse et ormolus and resysns entry. E entry is rem tit kapemashall have rcauat to the remettres provided by!air m s ae ems, The Commonwr"lt'ofMassachusetls t. =al - .Deporknent oflndustrinlAccidents = '' c, 1 Congress Street,Suite 100 . E lE(=:• •_ . Boston,MA 02114-2017 •; ....` •www massgovldia • - Workers'Compensation Insurance Affidavit:BuIIders/Contrectnxs/Electridans/Plnmbers- ' TO BE FILED WITf'1$E PEABII'TING All 1tIORI Y. Applicant Information Please Print Legibly . • Name(Bnsiaiss/Or�: - -. ,.c.� •• l(- C 11)5 5'i YI . Addles • City/Sta efEti: Phone#' - - Are Ever as employee/t scribe appmpsnta bv>= Type of project(required):' .1 . .1.0 I am a mpbyarwiffi cimibyem(ton orpnn-tree).• _ 7..0 New construction • OI sma sokpapticu or pansmship andbavcoo m>iilnya'°macing fuse in S.❑Remodeling - • my may.[Nuwohes'can-imorao<x xeqd.3J • 9. ❑Demolition, . 301 am abo®mwn?doing aIlwak*sal 1No wudm ea..ins Mmocmonmll/ • • 100BII1 gadernioa . • 4_❑Ism ahoasvwner end wIlbcl:icing cootamorstocomdoaaIlwadcensiypopetty.Iwill 11.❑Elecmtali yeuaoradditions omata#all oon owass ei hnismcwmins'omps�w imam=ot m sok • proisiciom wilhm®P>oyes 12❑plumbmgrepairs or aclrFficmc 50 fare agmealcnrm.=anti hevelmr3thcanb 5smdas fieMachedahem 131—IRDOfi as • 'These•o —+*� hav t+• e ea ployem swan e woakcs'comp.issuer i. • 'LJ • - 14-❑Other . . t E❑We as a cumathm sodas m5abave tbcirright of me pcIdCiin_ . . 152.§1(4),and we haven employes � s w (Howod inss 1. 'Any applcamt3ffi cb ktur s #1 ffis'talso Elm out srcib ond i ow slowing/ mam. Fob9 -t gommwnms wbo=bah this athdav[iodsatingthey am doing allwock and fism him=Mid==tractors mast ads.a s,, rtzvitin +ion such . . ;ContactocsMat check tbisbammmt attad.lan Matiorml riMet showing andsilae whether or not Hose eafitiec have m FacTc.s Mi.mb,..±.ctabava mploym. s • ' I am an employertibm is providmg workers'eompensaGmr insurance for my employees.Blow is the poacy and job rile • information. . . - . lnsce Company Name. V • m� Policy#or Gtf ins Lie � , Job Site Address: dedararnn a(showing the anmbe=and e:piraton date). . ' .«.,-;�py�f tha workers'eamprn<atioupoEry 1� �� . Fatlme to scone Coverage as required tinder MGL c.152,§25Ais a criminal violaprm prmichahle by a fine op to$1,500.00 • and/or ano-year imprisonment,as well as civil penalties in the ofa STOP WORK ORDER and a fine of np to$250.00'a day ag*tost the violator.A copy of this stateman maybe forwarded t•o the Office of Investigations of the DIA for insurance coverage vmfitxtion. . I do; curds thep®ss wedanir pe jwi the informafron provided above tree wad • • S . . Phonon •.Sags L' 3�-Q • - ._ Official sae only.Do.not write in tha area,to be completed by city or town official City. or Town. . ' P.r,.,,rrt;c curse# • Issuing Authority(circle one): L Board of Health 2-BmllTmg Department 3.Ctty/own Clerk 4.Electrical Inspector 5.Plumbing Inspector • 6.Other - - ' Contact Person: • Phone#l: .