HomeMy WebLinkAboutBLDP-22-007502 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
y,_ CITY YARMOUTH MA DATE 6/30/22 PERMIT# BLDP-22-007502
r JOBSITE ADDRESS 518 ROUTE 28 OWNERS NAME SANDBAR HOLDINGS LLC
P OWNER ADDRESS 518 ROUTE 28 WEST YARMOUTH,MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW:El RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El
FIXTURES • FLOORS—. RSM 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
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER 1
WATER PIPING 1
OTHER 1
OTHER DESCRIPTION:3 bay sink
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 David Houde LICENSE 16673 SIGNATURE
MP ❑i JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 1016 Queen anne rd
CITY harwich STATE Ma ZIP 026702445 TEL 5083940005
FAX CELL I EMAIL davidhoude6@gmail.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑
El
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY l "�(t •�i�v. h MA DATE O /�° / ^ PERMIT#
r.
JOBSITE ADDRESS / S-71 _ OWNER'S NAME ./WL r r a'a
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[c} "— EDUCATIONAL ❑ RESIDENTIAL❑
PRINT /
CLEARLY NEW:L7 RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—+ Bat 1 2 3 4 5 6 7 e 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND 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 J
ROOF DRAIN
{ SHOWER STALL •
SERVICE I MOP SINK
TOILET
URINAL
. j WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES /
WATER PIPING
OTHER /
13 c _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El.,16❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 11 OTHER TYPE OF INDEMNITY ❑ BOND 0
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
LI-1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the best my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in Banc with all Perti 'sion o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME - p;�„‘
LICENSE# /6 0 ).5 SIGNA URE
MP'JP❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME Al‘✓ 64- - P4 ADDRESS / 0//G Q(r-e r 1 c ue /(}.
CITY STATE ZIP 4ci b Lf �� TEL SZ r'.4 9
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT it
PLAN REVIEW NOTES