HomeMy WebLinkAboutBLDP-22-005726 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
e r-, CITY YARMOUTH MA DATE 417122 PERMIT# BLDP-22-005726
JOBSITE ADDRESS 66 PINE GROVE RD OWNER'S NAME VERNAL H DAVID
P OWNER ADDRESS VERNAL MARY F 26 CHASMARS POND RD DARIEN,CT 06820 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES❑ NO❑
FIXTURES Fl OORS—. 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 2
ROOF DRAIN
SHOWER STALL 1
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 m 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 alan Bishop LICENSE 3t1513 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME a.w.biashop plumbing and heating ADDRESS 23 denver st
CITY hyanni STATE MA ZIP 02601 TEL 17745529777
FAX I CELL 1 I EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES