HomeMy WebLinkAboutBLDP-21-004631 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
( 1,a CITY YARMOUTH MA DATE 2/16/21 PERMIT# BLDP-21-004631
.tr . JOBSITE ADDRESS 35 OYSTER COVE RD OWNER'S NAME jacob feist
P OWNER ADDRESS 35 OYSTER COVE RD SOUTH YARMOUTH,MA 02664-2320 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 2 1
ROOF DRAIN
SHOWER STALL 1 1
SERVICE/MOP SINK
TOILET 2 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER 1
WATER PIPING 1
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 0 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 LICENSE 34718 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑
COMPANY NAME ADDRESS
CITY L STATE ZIP TEL
FAX CELL I EMAIL
44.
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT El ❑
FEES S PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLING WORK
— it,_ CITY/TOWN Sa' �'"^ �C`f�m��"� MA DATE PERMIT# fiLD 2 f a0`�(r /
i'_•i�!_mad
JOBSITE ADDRESS ' Oy 53Y Cove- 12 OWNER'S NAME,,666 b Fa/
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL 0
PRINT
CLEARLY NEW: ❑ RENOVATION: 0 REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
FIXTURES Z FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK l
LAVATORY
ROOF DRAIN
SHOWER STALL 1 I
SERVICE i MOP SINK
TOILET Z 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING I
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES�0 ❑
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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 fP rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME /4/(C 174. r / ��l eere LICENSE#• >`/ 7"k SIGNAT
MP El JP .� CORPORATION ❑# PARTNERSHIP El# LLC❑#
COMPANY NAME Pi e urn,bi n j i���t�C i a'lS ADDRESS 4/ ke; Cec tAJ C"1
CITY ' '3 `lam'^ 17)65' 44 STATE, /1141 ZIP s--) 3 TEL
FAX CELL`77t/-7.2 `3.UUIEMAIL/w ?id-ece 7 7 /VWWI/. Co