HomeMy WebLinkAboutBLDP-21-005922 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
k 1 k,,,, CITY YARMOUTH MA DATE 4/13/21 PERMIT# BLDP-21-005922
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JOBSITE ADDRESS 277 ROUTE 6A OWNER'S NAME Phil Baxter
P OWNER ADDRESS 277 MAIN ST YARMOUTH PORT,MA 02675-1817 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
FIXTURES '< FLOORS-, BSM 1 , 2 3 • 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 6 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 7 4 ,
ROOF DRAIN _
SHOWER STALL 1 3 _
SERVICE/MOP SINK _
TOILET 7 4 ,
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 ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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.
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 James Parkhurst LICENSE 13223 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# _ LLC El#
COMPANY NAME JAMES P PARKHURST ADDRESS PO BOX 6273
CITY Plymouth STATE MA ZIP 023626273 TEL
FAX CELL EMAIL jparky317@yahoo.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes o
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
SJ, MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
..t9. CITY /a( t MA DATE q -13 - , PERMIT/ GLOP-21- 0059Z1_
JOSSITE ADDRESS 7 at OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er-
PRINT �/
CLEARLY NEW:0 RENOVATION:L7 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-, ISM I 2 3 4 5 6 1 II E9 10 11 12 13 14
. BATHTUB (o 1 - .-
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIIJSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK • _ .
LAVATORY 7 `-(
ROOF DRAIN
SHOWER STALL _I 3
SERVICE/MOP SINK • _
TOILET t.__,____ 7_. ► r
URINAL r--
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER _ r -
INSURANCE COVERAGE: ,/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES tK ND 0
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q/ OTHER TYPE OF INDEMNITY ❑ BLOND [..J
' OWNER'S INSURANCE WAIVER:I am aware that the licensee does_not Nye the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
1 hereby oerdly that au of the details and information I have submitted or entered regarding then application us true and e lo the best of my knowledge
and that a/plumbing work and msfasatwns performed under the permit issued Tor this application will be it al Pediment provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 3 AM"S LICENSE/ l / 2 a SIGNATURE
MP U1 JP❑ CORPORATION IJ -5 [ PARTN IP❑I LLC❑air
COMP NAIL 4 Frt-iADDRESS ) (oa 7
CITY r40-4 - - STATE 1 lk. ZIP Da3Cv TEL 5 W 7°0
FAX CELL EMAIL 3 (Alc 317 C QA0V Go 1