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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY YARMOUTH MA DATE 6/11/21 PERMIT# BLDP-21-007218
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E-i JOBSITE ADDRESSk,,,,,,
712 WILLOW ST OWNER'S NAME steve oddo
P OWNER ADDRESS 712 WILLOW ST SOUTH YARMOUTH,MA 02664-1106 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: El 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
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
OTHER 1
OTHER DESCRIPTION: irrigation backflow
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 Brian Kliment LICENSE#1770 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME BRIAN R KLIMENT ADDRESS 15 JULIA GRACE LN
CITY HARWICH STATE MA ZIP 026452300 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEES E PERMIT S
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`ini .....,..,...,....j MA DATE PERMIT #
_.. — CITY i�l,Zri?c $,' >r.� -
JOBSITE ADDRESS 7/.2 ✓i//v c,i .S"7, OWNER'S NAME 0 O De.-.)
POWNER ADDRESS TEL .. . . " FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL r EDUCATIONAL , RESIDENTIAL F
PRINT
CLEARLY NEW: [ RENOVATION: REPLACEMENT: j PLANS SUBMITTED: YES 0 NO
FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB l I+._ I NON;1 I 0 ,' .
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM I + E '
E
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM ''; I, Ali
DEDICATED GRAY WATER SYSTEM II _.__ . I ,4
DEDICATED WATER RECYCLE SYSTEM ! I '`
E i .E E E to ,`
. .
DISHWASHER ` '. I ; .., L . ..:,:
DRINKING FOUNTAIN '+ _ I I ;I I _.: . `
is j ,
FOOD DISPOSER ;i +
FLOOR /AREA DRAIN illitllIllrgllIllIIIIIIIIIIIIIIIIIIIIIIIIIIIllillIllillIlllillltIIIIIIIIIIIIIIIIIIMIIIIIII.
INTERCEPTOR (INTERIOR) IIIIIIIIIWIIIIIIIIIIIIIIIIIIINIFIIIIIKIIIIIIIIIIIIIIIIIIIIIIIINIIIIIIIIIIIIIIIFIIIIIF
KITCHEN SINK M NMI minetimitumnuma wmum
LAVATORY 11111111111i '
ROOF DRAIN _ _._ . _
E
1 F_ I l I, _._.,.r.._ ......_. :
SHOWER STALL I :i _. l
SERVICE / MOP SINK : .... _
I i C ''_ ,
TOILET �.�,, �� ��., . r..:.•_
URINAL iL. ! '
I
WASHING MACHINE CONNECTION WIIIIIIV i ! " +
WATER HEATER ALL TYPES �; �. _ �,, �,' 1
WATER PIPING iii
.. 3t I[. "1
:E
OTHER _ . �I � �i_� `
I ,,z a f c, r"�.v,- A e14 -/�L e ;I Ill"
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I . E_. ........_ .._... ._. ... ... "fit 1L •� � .. i �
iil it w_ i E W..
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E NO Ej
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Fl OTHER TYPE OF INDEMNITY E BOND El
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 (l AGENT 7
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 /2i�+� ` LICENSE # , /! 7 7e) SIGNATURE
MPR JP CORPORATION El# H ,PARTNERSHIP11# LLC #
COMPANY NAME Kt_irnc--,•r7 /9/.,',x 6, -•%' S4,rt id es ADDRESS /.. -f�'4 '/� 6...2.4ac-f .�N
CITY /ter+ R 4-4).4 ef STATE [ ?t.+ ZIP o ac -./_�' TEL Sv y - 7'7G - -�44/0
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FAX 'I CELL EMAIL Kt t-:ie 7 f'/�;..,S;fr-4- - ,/0.4 , el.,. _