HomeMy WebLinkAboutBLDP-22-005415 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
u I g , CITY YARMOUTH MA DATE 3/28/22 PERMIT# BLDP-22-005415
JOBSITE ADDRESS 49 HAYWOOD AVE OWNER'S NAME WILSON KIM M
P OWNER ADDRESS 49 HAYWOOD AVE SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT:El 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 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 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 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❑ 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 Ronald Hague LICENSE 1636 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑
COMPANY NAME RONALD J HAGUE ADDRESS 62 NEW BOSTON RD
CITY DENNIS STATE MA ZIP 026381901 TEL
FAX CELL EMAIL ronhague@comcast.net
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
\, r +� PERMIT# S ,i r
CITY - �` MA DATE a } 2 Z_ z
JOBSITE ADDRESS `I R R aiN, j � OWNER'S NAME b\ tr'N (S
OWNER ADDRESS - -1 ' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: Ea REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR-* BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE l
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
•
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1
ROOF DRAIN
SHOWER STALL I _
SERVICE/MOP SINK
TOILET
URINAL
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❑ 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
j Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
41 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. ��`/ j.
PLUMBER'S NAME LICENSE# b 3 . SIGNATURE
MP 71 JP❑ CORPORATION[]# PARTNERSHIP❑.# LLC❑#
COMPANY NAME � to t w— I `1 ADDRESS 6 l -,, 13 S �,, `2 ( _
CITY -Cv‘.‘^-k ) STATE '\'t�' ZIP C'�6 3 4' TEL k.M0 3 b y
FAX
CELL EMAIL .- v•-‘/\.c• (t, C ,n 4 t'
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES