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HomeMy WebLinkAboutBLDP-21-000878 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Uri CITY YARMOUTH MA DATE 8/21/20 UI� PERMIT# BLDP-21-000878 JOBSITE ADDRESS 36 ROUTE 6A OWNER'S NAME HEGARTY JAMES W TR 1 P OWNER ADDRESS J W&B HEGARTY TRUST P 0 BOX 327 CUM/QUID,MA 02637 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES-1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 i 12 13 14 BATHTUB 2 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 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 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❑ NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER TYPE OF INDEMNITY❑ BOND 0 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 (Brian Cameron LICENSE 3/727 SIGNATURE MP 0 JP ❑ CORPORATION ❑# 3727 PARTNERSHIP ❑# LLC ❑# COMPANY NAME Seaside Gas Service Inc ADDRESS 67 Helmsman Dr CITY Yarmouth Port STATE MA ZIP 02675 TEL 5087712768 FAX 5080000000 CELL 5084000943 EMAIL l /t - Ali_ err n - 1pu£ 44,44 6/2 ° iZ y1,gn- l1E1oe S,4/01,/ft fi AD£a'v47( Ha% h'4-%'4 /_;--t1 �2,5