HomeMy WebLinkAboutBLDP-22-004403 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�_, CITY YARMOUTH MA DATE 2/8/22 PERMIT# BLDP-22-004403
hln JOBSITE ADDRESS L61 5163 BERRY AVE OWNER'S NAME ALLEN NEAL L
P OWNER ADDRESS ALLEN LORETTA M 68 WESTWOOD DR STURBRIDGE,MA 01566 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:❑ 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
WATER PIPING
OTHER 1
OTHER DESCRIPTION:kitchen faucet replace
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO❑
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
OWNERS 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 DONALD BARROWS LICENSE MA I SIGNATURE
MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑H LLC ❑#
COMPANY NAME ADDRESS 175 maple st
CITY Stoughton STATE MA ZIP 00207 TEL L812977049
FAX CELL EMAIL
ROUGII PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES