HomeMy WebLinkAboutBLDP-22-001180 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
IT: CITY YARMOUTH MA DATE 9/1/21 PERMIT# BLDP-22-001180
JOBSITE ADDRESS MID-TECH DR OWNER'S NAME CAPE COD&ISLANDS ASSOC OF
OWNER ADDRESS 22 MID TECH DRIVE WEST YARMOUTH,MA 02673-2560 RExLTORS INC
p TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO El
FIXTURES • FLOORS 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 SYSTE
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _ 2 _
INTERCEPTOR(INTERIOR) 1 _
•
KITCHEN SINK
LAVATORY 2
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK 1
TOILET 1
URINAL _ 2
WASHING MACHINE CONNECTION _
WATER HEATER
WATER PIPING 1
OTHER 1
OTHER DESCRIPTION: Other-2-Bay Work Sink
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 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 Steven Henriques LICENSE 12245 SIGNATURE
MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Blue Hill Plumbing and Heating ADDRESS 344 John L. Dietsch Blvd
CITY North Attleboro STATE MA ZIP 02763 TEL 5086953711
FAX CELL 5086953711 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