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Home My WebLink AboutBLDP-22-005157 #A MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ CITY YARMOUTH MA DATE 3/16/22 PERMIT# BLDP-22-005157 11% JOBSITE ADDRESS 33A BAXTER AVE OWNER'S NAME CAULEY GREGORY M P OWNER ADDRESS CAULEY MARY D 33A BAXTER AVE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 1 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❑ 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 Patrick Dempsey LICENSE t>5176 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME PATRICK J DEMPSEY ADDRESS 26 LYME ST CITY EAST WEYMOUTH STATE MA ZIP 021891023 TEL FAX CELL EMAIL none ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT H PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :;i y 4 CITY \CnC MCI( C \ MA DATE 2 2- PERMIT# JOBSITE ADDRESS ) c,.><re< Ove__ OWNER'S NAME Mn*C\-f C�lCAe POWNER ADDRESS e)c,.�-e( TEL TEL FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 21 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR— 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/OIUSAND 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 ROOF DRAIN , SHOWER STALL SERVICE/MOP SINK TOILET , URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING x OTHER _ 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESf \ NO E IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW V j LIABILITY INSURANCE POLICY; OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the insurance coverage required by Chapter142 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 a 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 4,,m 'ance th II vent provision of the Massachusetts State PI bring Code and Chap r 142 of the General Laws. PLUMBER'S NAME ar2k • '1,4*.V-- LICENSE# /57 76` SIGNATUR M} "C JP[Ej CORPORATION 0# PARTNERSHIP 0# .LLC 0# ,` bin CC COMPANY NAME �DA c�\.0 De__AA ?5 `Turn RESS _ 5 pk.C ec .\ Co e`'� I C 1 CITY �5� e� STATE A ZIP OZ C `I 1 TEL U I I `0 0 66 7 FAX CELL 7S 17 10 06 6-7 EMAIL