HomeMy WebLinkAboutBLDP-22-005418 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/28122 PERMIT# BLDP-22-005418
�� ' JOBSITE ADDRESS 38 HOLLY LN OWNERS NAME MURPHY JOHN W
P OWNER ADDRESS GIRARD KAREN E 6 FRANKLIN DR TYNGSBORO,MA 01879 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 2
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 2
URINAL
WASHING MACHINE CONNECTION 1
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❑ 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.
PLUMBERS NAME Ronald Hague LICENSE 1636 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME RONALD J HAGUE ADDRESS 62 NEW BOSTON RD
CITY DENNIS STATE MA ZIP 026381901 TEL
FAX CELL EMAIL ronhague@comcast.net
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
- • 130
MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY �tA (vt �� MA DATE 7)\a�� � ) PERMIT# 21_ � 11€
o
JOBSITE ADDRESS �� l•ko \``I OWNER'S NAME "Su r:V 4" •A J ON,1
OWNER ADDRESS TEI1 1 y 3 3 = S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
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 I. •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN -
INTERCEPTOR(INTERIOR) r
KITCHEN SINK
LAVATORY t
ROOF DRAIN
SHOWER STALL • 1 •
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION �
WATER HEATER ALL TYPES
WATER PIPING
OTHER
.
I - -
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
UABIUTY 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
JS 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 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 Zv 01 A LICENSE* 1& 3 L . SIGNATURE
MP® JP❑ i t CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME KCMG w( , � ADDRESS L /y•{w (3P 1 �'�. a.t
CITY --1-A-''N. STATE 14-
ZIP 0 63
TEL (Pt) 3L.4 - cttd
FAX CELL EMAIL ry tkb) f .C) C001La f �,. .1 h
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES