HomeMy WebLinkAboutBLDP-21-004411 •
1' • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 2/4/21 PERMIT# BLDP-21-004411
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-_,„k s JOBSITE ADDRESS 425 ROUTE 6A OWNERS NAME HIRBOUR JOHN F TRS
P OWNER ADDRESS HIRBOUR ELIZABETH D 425 ROUTE 6A YARMOUTH PORT,MA 02675-1824 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES _j FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 01. l
DEDICATED SPECIAL WASTE SYSTEM Z�(1L ,./
DEDICATED GAS/OIL/SAND SYSTEM r
DEDICATED GREASE SYSTEM '2 W 4)
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK 1
LAVATORY _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK 1
TOILET
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
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 El 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.
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 Kevin Saunders LICENSEI308 I SIGNATURE
MP 0 JP 0 CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I I
COMPANY NAME (SEASIDE GAS SERVICE INC I ADDRESS 167 Helmsman Dr
CITY (Yarmouth Port I STATE IMA I ZIP 102675 I TEL 15087712768
FAX I I CELL 15084000943 I EMAIL I
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