HomeMy WebLinkAboutBLDP-21-005140 #104 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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r3 CITY YARMOUTH MA DATE 3/11/21 PERMIT# BLDP-21-005140
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tl: JOBSITE ADDRESS 345 CAMP ST y i c' 7 OWNER'S NAME CHARLES WHITE MANAGEMENT
P OWNER ADDRESS 330 COMMONWEALTH AVE BOSTON,MA 02115 INC TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO m
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 1
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 Michael Hansen LICENSE MA SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Rusty's Inc ADDRESS 222 Mid Tech Dr
CITY W Yarmouth STATE MA ZIP 02673 TEL 5087751303
FAX 5087719310 CELL 7742634177 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑
FEES$ PERMIT k
PLAN REVIEW NOTES