HomeMy WebLinkAboutBLDP-22-004005 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
xn CITY YARMOUTH MA DATE 1/20/22 PERMIT# BLDP-22-004005
JOBSITE ADDRESS 17 TERN RD OWNERS NAME'Daniel Baker
P OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURFS FLOORS—r RSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILJSAND 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
WATER PIPING
OTHER 1
OTHER DESCRIPTION:septic reroute
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 0 OTHER TYPE OF INDEMNITY 0 BOND❑
OWNERS 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.
PLUMBERS NAME 'Michael Mcbride I L!CENSE'1B681 I SIGNATURE
MP 0 JP ❑' CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑#I
COMPANY NAME 'MICHAEL R MCBRIDE ADDRESS 19 Rustic Drive
CITY 'West Yarmouth I STATE IMA I ZIP 102673 I TEL I
FAX I I CELL I I EMAIL Istinger.mcbride@gmail.com
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ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�=- "_. CITY 'M C (`''L MA DATE / A '7 �Z -'-- PERMIT# Z Z -(1Gv,r
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;N 19 I AD RESS I / 'f�'1 a2LC,� OWNER'S NAMETI - C� �❑
, ,, 1: G DE :AMER ESS ,j 91 V•1 7"h Y1 ✓ • 7 77 TEL 3 / 2 — 6.) IOS7AX
TYPCCUPANCY TYPE OMMERCIAL 61
"C EDUCATIONAL ❑ RESIDENTIAL lki
PRINT 5 (34 - z L
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:[ PLANS SUBMITTED: YES IR NO El
FIXTURES 1 FLOOR- 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 SYSTEM '
DISHWASHER •
DRINKING FOUNTAIN ' '
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK ' '
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL '
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
'
OTHER '-?�� -rib -r1 r /%7 /
'
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
UABIUTY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND LI
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i' Massachusetts General Laws, and that my signature on this permit application waives this requirement.
`,- CHECK ONE ONLY: OWNER ❑ AGENT ❑
Z SIGNATURE OF OWNER OR AGENT
L',l 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 Plumbin Code and Chapter 142
of the,General Laws. ` ���� `
PLUMBER'S NAME c‘C\ c/�7 LICENSE# SIGNATURE
MP❑ JP[K] , CORPORATION❑# PARTNERSHIP❑.# Pro
P LLC❑#
COMPANY NAME L�r� f CT L ( p -i-44 ADDRESS" n Lit 'l /����I (.'`€
CITY !✓ ;.f ,') ►') 1 <) STATE 1,/k4 ZIP 0 ? 0 / TEL 77 y 71 U A Z-Z
FAX CELL EMAIL i r J A r l( I L• s
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
1