HomeMy WebLinkAboutBLDP-22-004610 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
y, CITY YARMOUTH MA DATE 2/18/22 PERMIT# BLDP-22-004610
t, JOBSITE ADDRESS 248 CAMP ST UNIT A6 OWNER'S NAME COYNE KEVIN G
P OWNER ADDRESS COYNE ELLEN P&LAMA KERRY E 38 DUTTON RD STOUGHTON,MA 02072 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO D
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❑ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY 0 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 Richard Whiteside LICENSE/6850 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Murphy Services,Inc ADDRESS 34 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE 0 0
FEES$ PERMIT#
PLAN REVIEW NOTES