HomeMy WebLinkAboutBLDP-23-001367 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
a CITY YARMOUTH MA DATE 9/14/22 PERMIT# BLDP-23-001367
r{ JOBSITE ADDRESS 5 SYRITHAS WAY OWNERS NAME MCLAUGHLIN LAWRENCE D
``` P OWNER ADDRESS CIO MCLAUGHLIN KEVIN 15 DONNELLAN CIR WEYMOUTH,MA 02191 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
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
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET _
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER 1
WATER PIPING
OTHER 1
OTHER DESCRIPTION:backflow
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 0
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 at 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 at 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 brian hibbard LICENSE#1977 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS po box 429
CITY south dennis I STATE MA ZIP 102660 I TEL 15083982228
FAX I CELL I 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