HomeMy WebLinkAboutBLDP-22-006709 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
u f_ CITY YARMOUTH MA DATE 5/19/22 PERMIT# BLDP-22-006709
JOBSITE ADDRESS 14 WEBSTER RD OWNER'S NAME GODIN DAVID
P OWNER ADDRESS GODIN HILARY 185 NORTH MAIN ST SUFFIELD,CT 06078 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL ❑
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CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑
FIXTURFS • FLOORS—. ,BSM 1 2 3 4 5 6 7 8 9 10 11_ 12 13 _
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 1 _
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
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 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El 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 Alexander Eaton LICENSE#6715 SIGNATURE
MP ❑ JP ❑ CORPORATION D# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 50 long duck pond rd
CITY plymouth STATE MA ZIP 02360 TEL 5082805773
FAX CELL 5082805773 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yee No
THIS APPLICATION SERVE AS THE ❑ ❑
or ooee
FEES S PERMITS
PLAN REVIEW NOTES