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Home My WebLink AboutBLDP-21-006951 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4 c(Z CITY YARMOUTH MA DATE 6/1/21 PERMIT# BLDP-21-006951 JOBSITE ADDRESS 66 NORTH MAIN ST OWNER'S NAME CAMPBELL DOUGLAS A P OWNER ADDRESS CAMPBELL HEATHER A 66 NORTH MAIN ST SOUTH YARMOUTH,MA 02664 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 1 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 TOILET 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❑ 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 John Kane LICENSE 3Q755 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME JOHN KANE ADDRESS 39 MONOMOY RD CITY S YARMOUTH STATE MA ZIP 026641984 TEL FAX CELL EMAIL sjk1725@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMIT H PLAN REVIEW NOTES MASSACHUSET TS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK . r--..„..,, &) CITY 5 GJYAUV ', MA. DATE 6 ii. ( i 1. '2 I PERMIT#11kbP"It- o0V9S1 ��'' JOBSITE ADDRESS (a 4 N . h/1 a r h S ( OWNER'S NAME D 0 tiv cop Ibr Ii POWNER ADDRESS Serkn t TEL SO S a Is O -O?'o O FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL [I RESIDENTIAL a PRINT CLEARLY NEW: ❑ RENOVATION: Zc REPLACEMENT: ❑ PLANS SUBMITTED:TED: YES ❑ NO 2 FIXTURES 1 FLOOR— IBSMT111213141516170 9 10 1 i I 12 I 13 1 14 BATHTUB I I I I CROSS CONNECTION DEVICE I I I I I II I DEDICATED SPECIAL WASTE SYS Ii I I I II I DEDICATED GAS/OIUSANDSYS I I I I I I I I DEDICATED GREASE SYS I I I I I 1 DEDICATD GRAY WATER SYS I I I I I I I I I DEDICATED WATER RECYCLE SYS I I I II I DRINKING FOUNTAIN I I I I I I I I DISHWASHER I I I I I I I I FOOD DISPOSER I I I I I I I I I FLOOR I AREA DRAIN I I ( I I I I I I INTERCEPTOR ERCEPTOR (INTERIOR) I I I I I I II KITCHEN SINK ( I I I I I II LAVATORY -- - I I I I I I i I _ J _ ..Y_ --.-1 ROOF DRAIN-- I I i I I 1 I I t z ;, `r I SHOWER STALL I 1 I I I I I t 1 1 - - I SERVICE I MOP SINK I I I I I I 1 i I I I TOILET i I I I I I I I ` i'' ).;ZII URINAL I I I I I I I 1 1 I 1 I WASHING MACHINE CONNECTION I I I I 1 I i r � , `, : .I. i r - *j I�L'1 L N- WATER HEATER ALL TYPES I I I I I I , _1 __ . L _ WATER PIPING I I I I I I I I I I OTHER I I I I I I I I I I I I I I I I I I I I I I I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142 Yes 12 No 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2,- OTHER TYPE OF INDEMNITY ❑ BOND 0 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's 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 NAME , a\in K.q rte., • SIGNATURE Y7(16( LIC# --�1 SS- 5- MP ❑ JP [_ CORPORATION ION ❑# PARTNERSH 0# LLC ❑# COMPANY NAME 70 cl< 1�o rc P i b 9 ADDRESS: 3 c1 P7 I r) a m a i/ 11 J • CITY S . y Q tr iev" STATE Uh u ZIP b )( 6. 4 EMAIL' S .7 K I 1 a- 3- A Q PY► _` I � C 0 TEL S D ' G ?S'- SC S7 CELL FAX Cd4j4 • ri z 0 z z 0 T -I m S m � -a a r w Ij z n Z m =y c O m - �- co R C 0 L/] ❑❑o� GD O m z r � z z n a 0 z z 0 t7 rn