HomeMy WebLinkAboutBLDP-22-002357 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Vif CITY YARMOUTH MA DATE 10/25/21 PERMIT# BLDP-22-002357
JOBSITE ADDRESS 63 ABELLS RD OWNER'S NAME SHEA ROBERT D
P OWNER ADDRESS SHEA CARLA 63 ABELLS RD SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El
PRINT
CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED'. YES❑ NO❑
FIXTURFS FLOORS—, RPM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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
SERVICE/MOP SINK
TOILET 2
URINAL
WASHING MACHINE CONNECTION 1
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 m NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 Jordan Medeiros LICENSI'f6366 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Jordan's plumbing and heating ADDRESS 873 tradewind st
CITY New Bedford STATE MA ZIP 02740 TEL 5088639518
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE El ❑
FEES$ PERMIT#
PLAN REVIEW NOTES