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HomeMy WebLinkAboutBLDP-22-004836 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK yfi CITY YARMOUTH MA DATE 3/2/22 PERMIT# BLDP-22-004836 JOBSITE ADDRESS 31 LAKELAND AVE OWNER'S NAME MARKLE HARRY P OWNER ADDRESS MARKLE NANCY L 31 LAKELAND AVE SOUTH YARMOUTH,MA 02664 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 1 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 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 Daniel Smith LICENSE 36996 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 79 East Osterville Dr CITY Osterville STATE MA ZIP 02655 TEL FAX I CELL EMAIL IDANIELL12@GMAIL.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _1F=.t CITY .0-1 MA DATE 'Z ZL PERMIT# � t-1p3b JOBSITE ADDRESS I l \;LW;\i A\ OWNER'S NAME 0,kill -i OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL} PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:( PLANS SUBMITTED: YES ❑ NO[3,' FIXTURES 7. FLOOR-+ BSM 1 2 3 4 5 6 7 8 5 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY r ROOF DRAIN t ma 0 2 21127 i SHOWER STALL •- L_ SERVICE/MOP SINK TOILET — BUIL.VINr�r ent rvcp4 URINAL av . 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[ "NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D. OTHER TYPE OF INDEMNITY ❑ BOND ❑ i 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 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 tovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J PLUMBER'S NAME LICENSE# (7L 3�{��t(� .. � SIGNA E MP ❑ JP CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME I) ) 11Lt)VI R-Ci. : Nl)A C ADDRESS 75 GAS t US i( WE LLt CITY VJT e .1-Lt F STATE Al- ZIP C LLo)S TEL Z U0 ¶T(o'7G FAX CELL EMAIL )F e. ?LUJ"l13 Clrt.Lcti1/4 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