HomeMy WebLinkAboutBLDP-22-004922 #A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
y1 CITY YARMOUTH MA DATE 3/7/22 PERMIT# BLDP-22-004922
�� JOBSITE ADDRESS 27 BRIAR CIR A OWNER'S NAME COONEY PETER
P OWNER ADDRESS LUCAS CAROLE 27 BRIAR CIRCLE SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
FIXTURFS 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 1
ROOF DRAIN
SHOWER STALL 1 1
SERVICE/MOP SINK
TOILET 1 1
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❑
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 An Truong LICENSE 30771 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# _ LLC ❑#
COMPANY NAME AN H TRUONG ADDRESS 8 WORDSWORTH ST
CITY RANDOLPH STATE MA ZIP 023682116 TEL
FAX CELL EMAIL truongplumbing@icloud.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
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"—Rim, ,E„.m.l. _— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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IV-: CIT '/ipALI ( 1+ MA DATE 3 3 '- 2 C / PERMIT# Z SZZ`= 202
OBJITFT ADDRESSa,7- i'DQ/4 R C I le Lr/V! i A OWNERS NAME
I `B U LOIN �t-A rt itJJEJ R ADDRESS_3g fen C j ✓� 7 TEL Gl7 5 F 7 �, AK
Y
/TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL V
PRINT
CLEARLY NEW:❑ RENOVATION:Er REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _ _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _ - H
DEDICATED GAS/OIL/SAND SYSTEM '
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM —"
DISHWASHER /
DRINKING FOUNTAIN gtgr .
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
LAVATORY /
ROOF DRAIN
l SHOWER STALL /' f
• SERVICE/MOP SINK
TOILET / r
URINAL
. j 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. YES Njr-NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY ['V OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
k-:I 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. 2e—: Vr/I7')—) —''' '
.]
PLUMBER'S NAME A!Y eii01j LICENSE#3 6 / /. / SIGNATURE ,
MP❑ JP NV--
CORPORATION 0, # PARTNERSHIP�❑� .J# LLC❑# jj /_
COMPANY NAME/7A( /gtl d G)c~ fJl)ar'4%�i. I DRESS ' Ala.^1.) 0 TZ ii cl
CITY -r mod Aair STATE,I sr� ZIP 0 2 C 1- r TEL 17 P?O 6�16
FAX CELL EMAIL 'Al
icd GS ,
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES