HomeMy WebLinkAboutBLDP-23-004032 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r CITY YARMOUTH MA DATE 1/23/23 I PERMIT# BLDP-23-004032
/1i
JOBSITE ADDRESS 21 LITTLE DIPPER LN OWNERS NAME LECLAIR STEPHEN T
P OWNER ADDRESS LECLAIR BARBARA 40 HOLLY LN BRIDGEWATER,MA 02324-2833 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES FLOORS-. BSM 1 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
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❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 Kenneth Duarte LICENSE WA11012 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# l PARTNERSHIP ❑# LLC ❑#
COMPANY NAME [ ADDRESS 37 collins ave
CITY Centerville STATE MA ZIP 026322345 TEL
FAX 7 CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
1es No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES