HomeMy WebLinkAboutBLDP-22-001365 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH [MA DATE �919/21 PERMIT# BLDP-22-001365
t= JOBSITE ADDRESS 156 SWAN LAKE RD OWNER'S NAME CIFELLI GEORGE W
P OWNER ADDRESS CIFELLI ANN 156 SWAN LAKE RD WEST YARMOUTH,MA 02673 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 2
LAVATORY 4
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 3
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 as 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 justin hogg LICENSE 312412 SIGNATURE
MP El JP ❑ CORPORATION ES PARTNERSHIP ❑# LLC ❑it
COMPANY NAME Justin Hogg Plumbing&Heating Inc. ADDRESS 63 swift brook rd
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 5082373694
FAX I CELL I EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
l'es No
THIS APPLICATION SERVE AS THE d{� 10 c rs
FEES$ PERMIT#
PLAN REVIEW NOTES