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HomeMy WebLinkAboutBLDP-22-005816 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/12/22 PERMIT# BLDP-22-005816 1, JOBSITE ADDRESS 63A WILLIAMS RD OWNERS NAME Adam Goodrich P OWNER ADDRESS 02132 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL CI RESIDENTIAL El PRINT CLEARLY NEW:❑ 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:irrigation backflow 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❑ 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. PLUMBERS NAME Brian Kliment LICENSE 111770 SIGNATURE MP ©i JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME BRIAN R KLIMENT ADDRESS 15 JULIA GRACE LN CITY HARWICH STATE MA ZIP 026452300 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —i' , _ ...__N,r� �_ : CITY I _yit-.M1wL�r�� . __�F MA DATE /�1�� �� zL PERMIT # / z 5 1 ''�� � JOBSITE ADDRESS Gy lv.��i.�m � -- ----� �__ _ _' � A . 4/3_.._ f2o OWNERS NAME' _ , do, , i t-_____ x___,_..._..,..______ OWNER ADDRESS TEL ! FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Li RESIDENTIAL L PRINT CLEARLY NEW: ' RENOVATION: R_ r REPLACEMENT: PLANS SUBMITTED: YES ' I NOD FIXTURES Z FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE mM.—i JIM im_____!',a- m gmR 1----_--,_—“-_-_ rI-M W- I I: - ------_ O N---• M. -E-- _ai, -- r DEDICATED SPECIAL WASTE SYSTEM ___ _I _ ,. . 1r I—, - .___DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM .-- n1. I Mill DEDICATED GRAY WATER SYSTEMW - I __,_, _i'M t i DEDICATED WATER RECYCLE SYSTEM I mil i_ i�;�- ; _�`: . �-- ' lingitm DISHWASHERRIM �' �JR � '- DRINKING FOUNTAIN � � �� + � , I ;! _ ► _ FOOD DISPOSER MIMI Nil 1111111111111111111111Millip0.1 1,��I FLOOR 1 AREA DRAIN alaMnt f INTERCEPTOR (INTERIOR) , _ i IIIIIIIIIIIIIIIIMIMIMIIIIEIII KITCHEN SINK _- _;` f � �' rw LAVATORY . _ � ,.__--- - - - i ��-�,PM .. ..��..�.�� �._ I Mai ROOF DRAIN _ 1 SHOWER STALL WI unillinum iniiIMIMMinit - SERVICE l MOP SINK 1111.1WEIF111111111111111W111111111111111.111111111747. TOILET NM nit aim gm IIIIIIIIIIII 11111111.1.MN MIR iz MEi URINALM ;' — IMINEMIMIll WASHING MACHINE CONNECTION WATER HEATER ALL TYPES MI MI ME AM 1111111111111111111111 MO IMO 1111111_1111111111111114.11 MU MS WATER PIPING IIINFIIIPIWI _.. ,r N_ OTHER _ 1 ,_,..m_..m,_ . _,_. ___, _ .___r���,.,._ .._,_,_T..._ __ _____., i _ T. _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES v_ NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY A- OTHER TYPE OF INDEMNITY i ' BOND . l 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 I 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME .z, 2 rtN ta.s -it r I LICENSE # ROM SIGNATURE MP JP El CORPORATION 0# i PARTNERSHIPD# LLC 0# COMPANY NAME Kc!.�� r ADDRESS LN __..___.. ...._... fir.._M�_..T_-_✓___�,u.....� , ...._... CITY / 4f02 size STATE .77 ZIP FAX CELL 1 EMAIL i�/.�r,,-7 ,o4�6xhr,1y a , / • cv4(