HomeMy WebLinkAboutBLDP-22-005917 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
y, CITY YARMOUTH _I MA DATE 4/15/22 PERMIT# BLDP-22-005917
sJOBSITE ADDRESS 39 TODD RD OWNER'S NAME DAVENPORT DEWITT TR
P OWNER ADDRESS DAVENPORT REALTY TRUST 20 NORTH MAIN ST SOUTH YARMOUTH,MA TEL
02664
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
FIXTURES • FLOORS—r 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❑ NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 jeffery ricardo LICENSE 18256 SIGNATURE
MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME (patriot plumbing inc ADDRESS 1538 federal furnace rd
CITY Iplymouth STATE IMA I ZIP 02360 TEL
FAX I CELL 5088464551 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES S PERMIT#
PLAN REVIEW NOTES