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HomeMy WebLinkAboutBLDP-22-006094 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/22/22 PERMIT# BLDP-22-006094 rl JOBSITE ADDRESS 511 ROUTE 28 OWNER'S NAME LUKE ARTHUR TR P OWNER ADDRESS 511 MAIN STREET TR 511 ROUTE 28 WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:© RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO El 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 1 OTHER 1 OTHER DESCRIPTION:ice machine INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 LICENSE 18699 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS CITY STATE ZIP TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEESS PERMIT# PLAN REVIEW NOTES 47 " =2� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ar11�= tt CITY L y4e066,1 k I MA DATE I V13 ZZ j 'PERMIT# 22 (, a`)1_ JOBSITE ADDRESS1-141emainillimkt6-I I I - 24 'OWNER'S NAME I L S l vo+2_.S\a2c,... OWNER ADDRESS I I TEL'SOS' 7 7S-j cC I FAX Sece't -1,?p TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:S . RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO Kl FIXTURES 1 FLOOR-. 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 SYSTEM _ DISHWASHER .4._ _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK " LAVATORY i + , ROOF DRAIN , SHOWER STALL ' r _ SERVICE/MOP SINK I TOILET ~ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING____ /OTHER .-CCe- WNAC1/41-w 1 — 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. CHECK ONE ONLY: OWNER❑ AGENT❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ar: roll MO . ' t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in«. pli"l�de '• - t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME /A ' `' ' S :C!GAN.,4,e� ; LICENSE# 13E; y� Or SI "TUR_ MP[El\ JP ❑ i 309' CORPORATION,.#I3C Lt - PARTNERSHIP❑#I I LLC ❑#I I COMPANY NAME ���kSA•ti t Y v"�44.u� -3-;"4� ADDRESS!Y3 0_1 k,�;t,pe`,�,�C.�,LC- 4ti V I CITY V-- „.ac- :5_ .-uZ STATE kf•-'1!! ZIP I G 2 E::St I TEL 177'( 71.2_ '1. -, I FAX CELL EMAIL! C�cikS:l-��,yl \,%-,w\41_ [�, CG:;-�CJtS 1 r 4(.1 1