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HomeMy WebLinkAboutBLDP-21-000335 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 9-!) CITY YARMOUTH I MA DATE 7/22/20 PERMIT# BLDP-21-000335 JOBSITE ADDRESS 26 MINDEN LN OWNER'S NAME BEARSE JOYCE P OWNER ADDRESS P 0 BOX 258 YARMOUTH PORT,MA 02675-2028 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL ❑ PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO©' FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 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 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 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❑ NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE 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'S NAME John Perez LICENSE 4325 SIGNATURE MP El JP El CORPORATION ❑# 4325 PARTNERSHIP ❑# LLC ❑# COMPANY NAME Harbor Master Plumbing&Heating ADDRESS 7 Van Gogh Drive Inc CITY Osterville STATE MA ZIP 02655 TEL 5084191592 FAX 5084191592 CELL 6035914663 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No Qk /a 41 c.rs THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMITR PLAN REVIEW NOTES