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Home My WebLink AboutBLDP-21-004420 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 0. CITY YARMOUTH MA DATE 2/4/21 PERMIT# BLDP-21-004420 JOBSITE ADDRESS 95 OLD MAIN ST OWNER'S NAME TRAUB JEFFREY J P OWNER ADDRESS TRAUB LORRAINE F 95 OLD MAIN ST SOUTH YARMOUTH,MA 02664-6009 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 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 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK 1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 _ 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 Jared Wilber LICENSE 1;6219 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME JARED WILBER ADDRESS 474 WINSLOW GRAY RD CITY S YARMOUTH STATE MA ZIP 026644317 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT El FEES$ PERMIT H PLAN REVIEW NOTES T - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • FIL---_--. .-....... .ii • =L� CITY VCA,C \ MA DATE 2 7O _ JOBSITE ADDRESS 6A 5 U « a v ts V OWNER'S NAME p \no.-ir POWNER ADDRESS 6'G-irn e TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL .._ RESIDENTIAL 1 1 ..„• I CLEARLY NEW: 7. RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES ❑ NO ❑ FIX—U RES - FLOOR--} BSlvl 1 2 3 4 5 6 7 B 9 1 D 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM 1 _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN _ INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN . SHOWER STALL _ i . , . SERVICE 1 MOP SINK l I TOILET URINAL . WASHING MACHINE CONNECTION I I •I - WATER HEATER ALL TYPES WATER PIPING 1 OTHER 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES eJ NO ❑ . I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY "i 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 ❑ t� SIGNATURE OF OWNER OR AGENT E\ 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. C Ifiv'S PLUMBER'S NAME LICENSE # i 6:3-1 l 9 I SIGNATURE MP Fr JP 7 CORPORATIONi # PARTNERSHIP ❑.# LLC 0 # COMPANY NAME J (kr'e Jc IA ItilADDRESS I & 10 vi, /iv 1,git* IL CITY Y ay Yh v vti V, STATE ri)GC ZIP C) . i(;F1 TEL:::5_1L.NUI 3331Y2L____ FAX CELL Q EMAIL j CLY v IA Z J m40 I . c 0. tril ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIC N NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES w