HomeMy WebLinkAboutBLDP-22-005366 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/24/22 PERMIT# BLDP-22-005366
I_}. JOBSITE ADDRESS 74 WILFIN RD OWNERS NAME RUBIN BLAKE J
P OWNER ADDRESS RUBIN LORRAINE D 23 BRICE CIR HOLDEN,MA 01520 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES • FLOORS—. BSM 1 2 , 3 4 5 fi 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
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
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 El 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 as Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME William Heath LICENSE'12021 SIGNATURE
MP ❑ JP ❑ CORPORATION DO 1 PARTNERSHIP ❑# J LLC ❑#
COMPANY NAME WILLIAM 0 HEATH ADDRESS 45 Main Street
CITY Sandwich STATE MA ZIP 02563 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE 111
FEES S PERMIT#
PLAN REVIEW NOTES
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY : y Ater? tf7�, . ; MA DATE 3 `ZZ L Z PERMIT #
•ik,7.2,-.) ____,__ _____ --1 r- ___
JOBSITE ADDRESS '7 Y t✓rc 1,A/ 2 .).1 S; s?2 OWNER'S NAME i 1
P OWNER ADDRESS iiIxxi _ ii__i_ x__v_�._- _.-___ TEL �G -� 'cam Z y,� F'o'X
4.
TYPE OR OCCUPANCY TYPE COMMERCIAL ^�' EDUCATIONAL __ RESIDENTIAL
PRINT _
CLEARLY NEW: RENOVATION: [.__ REPLACEMENT: s _ PLANS SUBMITTED: YES j NOE
FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB - ---- - - _ - - L_ -- —i -r ---i =- ._ _, _._ ��-� ,.-______ . _I,
i_ i ,
CROSS CONNECTION DEVICE _ f� — - ;
DEDICATED SPECIAL WASTE SYSTEM k -_ _ s_ _ ' _ 11——! l;��-"— j 71— _ 7��r
DEDICATED GAS/OIL/SAND SYSTEM E 1 IT- ...11--- t -
DEDICATED GREASE SYSTEM i___ : au �y Tom_ it _ -- ,r
DEDICATED GRAY WATER SYSTEM -_ . _ _._ ' I_ - +- - [g.� 1
_ ... i It j g 4 J i,« ;__� -
DEDICATED WATER RECYCLE SYSTEM _..._ �_ w_ ,, _�.:,____� -1 __.I t .j )1 I
e ,,
DISHWASHER - - - ---- _ 4------ :r---_ _-- _______ _..___�,, 4--
, ___ t"--.---
L— _ � _mil .. t— 7-7
�— —� -J�---.�f�e tom_
DRINKING FOUNTAIN �� ! ? fi._. _�I � -�
FOOD DISPOSER € _._ 1=.—_.-..,�..__ ,- tr--17--1 --_-- 1�-----,f-------sr-- 7 , --- 11
FLOOR/AREA DRAIN ,E- r---- _ .- ? __ I� �` ;i
3_`__.) •_ �_S,_ i r_____ .. 3.._+ i _11 ' .,_ __ I Fes_ € 1 I
___ _
INTERCEPTOR (INTERIOR) f 4.....---
--.. r- , .. `�f Is __
KITCHEN SINK I _._ _^ __.. ;# ty _fi t� _.. _ A kf_ A 1
LAVATORY it - (r-----__- -- I; y _.. _ - .1 1 -- ; —. [ _._. ;_
il
ROOF DRAIN r _ i "i
SHOWER STALL ,1 ...'rtt-+ = -- M -71 1.._�..�_ ' _--I I .._._- 1 _. 1T_-� l....
SERVICE / MOP SINK _ _ _ iT� t xg" i'
TOILET = �•: _.T_ 3�--„Si 7. . !� .. w _ --� r - f
t A
_ _
URINAL u , -I l' '
WASHING MACHINE CONNECTION a_.� __ _. ,'___:_____..1 .,._ ,�_ y-. --.__.. s1.__.._. .�`_�_ � _ !.._._._.. k. , ! , I
WATER HEATER ALL TYPES I_ _ I t {ii
,-.. _._. .....,. , 1 _.,..... ,�... _y am_. �'�. '_........
l" 1 '
WATER PIPING _ ,
OTHER i (j/ LtIr ( #t,tdS ,�-firr' al €� ,i li {i 1
.i_ —. €stlRfflit'l1t 1:. rimi - : : cLJ
.._.sY, _.,.._._..._._l,. -►-7niaa. �' ____,____11, ...
lMAM. MraY1.� i 51 i''1 —__ � Imo. 3�` ! �E
1{rs..r.-.ye-nnu ..s_-._m..-d_t_� }c •r..r-fees-o ++r4,.w+r«rerml ..a r-. 3_;. ._
I H
INSURANCE COVERAGE:
I have a current liability insurance pa'icy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO t
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ' "V 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 i_-_.•
SIGNATURE OF OWNER OR AGENT
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.
7'ee.
PLUMBER'S NAME Ejv' -' / LICENSE # _ 7l-4=�-/ SIGNATURE
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MP Lv" JP L CCORPORATION Lim IPARTNERSHIP Litt!
I LLC . ]#j
COMPANY NAME 16 -4 5e _✓t Co _ ADDRESS i ('S s-rt .� ,J-r uti r
CITY! ) i a-�9 w i c)- a STATE i-y7 4-- ZIP [ O Zi.0 3 TEL jJ'O. -7 7 G- l u 0
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FAX ' CELL �77y ��7 EMAIL `3� l� �� T 3 E� �'y� � . (� -»
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