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Home My WebLink AboutBLDE-21-001450 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK A k (� CITY YARMOUTH MA DATE 9/22/20 PERMIT# BLDP-21-001450 e t' ri JOBSITE ADDRESS 24 ROUTE 6A OWNER'S NAME GALE CHARLES E TRS P OWNER ADDRESS GALE CAROLYN A 24 MAIN ST YARMOUTH PORT,MA 02675-1618 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES NO El FIXTURES FLOORS---+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER WATER PIPING 1 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY❑ 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 Leland Scott LICENSE 26186 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME LELAND SCOTT ADDRESS PO BOX 1635 CITY WELLFLEET STATE MA ZIP 026671635 TEL FAX CELL EMAIL a'r--- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEE PERMITS /Q,/j PLAN REVIEW NOTES C C /� , - - . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j _'ins '1�" , ! "' ; MA DATE- Otli) 2i Ob1 _ CITY/TOWN Yet, 4511 PERMIT#/ �` Q.fflo( t JOBSITEADDRESS •, �' ' 011llNAME Ze V) H) C-1(5. I' OWNER ADDRESS Tian, . TEL_ 17 ,95 9tj' 64 1 TYPE OR OCCUPANCY TYPE COMMERCIAL n EDUCATIONAL ❑ RESIDENTIAL V/ -- PRINT PLANS SUBMITTED: YES ❑ NO ❑ CLEARLY NEW: ❑ RENOVATION: 11 REPLACEMENT: ❑ FIXTURES TL FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB If CROSS CONNECTION DEVICE - _ DEDICATED SPECIAL WASTE SYSTEM _ - -t4). 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) _ _ _ _ r. KITCHEN SINK = - LAVATORY cf. ROOF DRAIN SHOWER STALL ' 91 • SERVICE /MOP SINK , . TOILET __ __ -- — -- --_ URINAL CT►ON I VIIASHING MACHINE CONNE - k WATER HEATER ALL TYPES _ t WATER PIPING • it • 4. ,• ,-f. OTHER _ 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 signat n this permit application waives this requirement. N. CHECK ONE ONLY: OWNER AGENT ❑ S1GNA AGENT • . I hereby rti a I of the details a formation I have submitted or entered regarding this application are true and accurate to the be f my knowledge and that plumbing work and inst ations performed under the permit issued for this application will be in compliance with all Pertinen rovis_io_ n of_ the Massachusetts State Plumbing de and Chapte;2feneraJ Laws. - PLUMBER'S NAME 4 LICENSE# SIGNATURE MP ❑ JP [ CORPORATION ❑ # PARTNERSHIP I I # LLC 0 # . COMPANY NAME e5"6t3rart •ADDRESS i s ''/ ! I i- ;' ; r lb if Y CITY ' ' STATE : =� ZIP k f TEL56,-.6---; _, ,_ FAX. • CELL666 62 16 3 EMAIL • PIN - •