HomeMy WebLinkAboutBDP&G-22-004206 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1
q,y CITY YARMOUTH MA DATE 1/27/22 PERMITH BLDP-22-004206
''' JOBSITE ADDRESS 13 LAMBERT RD OWNER'S NAME HOLLINGSWORTH JOHN A(LIFE
P OWNER ADDRESS HOLLINGSWORTH NANCY B 13 LAMBERT RD SOUTH YARMOUTH,MA 02LEng TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 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 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 0 NO 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.
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 charles Stockdale LICENSE MA I SIGNATURE
MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑H LLC ❑H
COMPANY NAME CLS Plumbing I ADDRESS 256 Mayfair Rd.
CITY South Dennis STATE MA ZIP 02660 TEL
FAX CELL 7742081613 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ El
rtrnaser
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
jj CITY YARMOUTH MA DATE January 27, 2022 PERMIT# BLDP-22-004206
JOBSITE ADDRESS 13 LAMBERT RD OWNER'S NAME HOLLINGSWORTH JOHN A (LIFE EST)
G OWNER ADDRESS IHOLLINGSWORTH NANCY B 13 LAMBERT RD SOUTH YARMOUTH MA 02664 423 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT: El PLANS SUBMITTED: YES 0 NO El
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 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 El
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY 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-GASFITTER NAME charles Stockdale LICENSE# ,MA SIGNATURE
MP ❑ MGF ❑ JP El JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME: CLS Plumbing ADDRESS. 256 Mayfair Rd.,
CITY South Dennis STATE MA ZIP 02660 TEL
FAX CELL 7742081613 EMAIL
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