HomeMy WebLinkAboutBLDP-21-005583 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ir a CITY YARMOUTH MA DATE 3/29/21 PERMIT# BLDP-21-005583
17-54)
JOBSITE ADDRESS 737 ROUTE 28 OWNER'S NAME jenia desilva
P OWNER ADDRESS 891 ROUTE 28 SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
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 1
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 1
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 D
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 Joseph Halloran LICENSE V984 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME JOSEPH M HALLORAN ADDRESS 29 Forest Glen Rd
CITY Hyannis STATE MA ZIP 026012537 TEL
FAX CELL EMAIL sowdawg@comcast.net
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY/TOWN ,/Y>L- �'� MA DATE 3 Z S" "�� PERMIT # P L -�z�s j 3
-` 3 '7 , rt
JOBSITE ADDRESS 7 OWNER'S NAME Jit/V r 574,4
OWNER ADDRESS 2 �v/( L �,L 5 .t/e/i6t, F 4 ,M1j TEL / 7 7A.5°
2�
o S3
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ( '"
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: [ PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES 7 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 SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I 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 /
OTHER
INSURANCE COVERAGE:
I have a current liabilityinsurance policyor 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.
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 are true and accurate to the bes f knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli wit "al ertin nt r on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER'S NAME j e� N4-00 MA/ LICENSE # /0 C 7 SIGNATURE
MP [r JP ❑ CORPORATION # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME i_c>. PIAs P2 u /v9ADDRESS c/ 1:ci I 15 I CLiI iv 1
CITY /474.N N J $ STATE'} ZIP 2- 6 TEL --c c' 2- 0 37
FAX CELL EMAIL 5 o wail w r0,44 C 4 5 /, �V j