HomeMy WebLinkAboutBLDP-22-003328 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 12/10/21 PERMIT# BLDP-22-003328
JOBSITE ADDRESS 33 CAPT YORK RD OWNERS NAME QUINTILIANI DOUGLAS R
P OWNER ADDRESS QUINTILIANI LAUREL A 33 CAPT YORK RD SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW:El RENOVATION:El REPLACEMENT:ElPLANS SUBMITTED: YES❑ NO El
FIXTURES FLOORS—, RSM 1 2 3 4 5 fi 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
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
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 El 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 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 at Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Eric Whiteley LICENSE 16920 SIGNATURE
MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME W Vernon Whiteley,Inc ADDRESS PO Box 1266
CITY West Chatham STATE MA ZIP 02669 TEL 5089451100
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES