HomeMy WebLinkAboutBLDP-22-005918 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
u=)"_ CITY YARMOUTH —I MA DATE 4/15/22 PERMIT# BLDP-22-005918
f1 JOBSITE ADDRESS 182 BAXTER AVE OWNER'S NAME GREEN HARBOR VILLAGE LTD
OWNER ADDRESS 20 N MAIN ST SOUTH YARMOUTH,MA 02664-3150 PART TEL
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TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
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 3
WATER PIPING
_OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current IiabilitYinsurance 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 cf 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 Sate Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME jeffery ricardo LICENSE 113256 SIGNATURE
MP ❑ JP ❑I CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME patriot plumbing inc ADDRESS 538 federal furnace rd
CITY plymouth STATE MA ZIP 02360 TEL
FAX CELL 5088464551 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑
FEES$ PERMIT#
PLAN REVIEW NOTES