HomeMy WebLinkAboutBLDP-22-004603 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 2/18/22 PERMIT# BLDP-22-004603
JOBSITE ADDRESS 875 GREAT ISLAND RD OWNER'S NAME CUSHMAN CLARE
P OWNER ADDRESS 4717 ESSEX AVE CHEVY CHASE,MD 20815 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑
FIXTURFS FLOORS 8SM 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 2
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 2
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❑ NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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 Slate Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Matthew Freitas LICENSE 26664 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME MPF PLUMBING ADDRESS 140 Crocker Road
CITY West Barnstable STATE MA ZIP 02668 TEL 5087375567
FAX CELL 5087375567 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
nrmarr
FEES$ PERMIT#
PLAN REVIEW NOTES