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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 7/11/22 PERMIT# BLDP-23-000155
JOBSITE ADDRESS 95 PINE CONE DR OWNERS NAME HAYES DANIEL F
P OWNER ADDRESS HAYES MARCELA M 11 DARLENE DR SOUTHBOROUGH,MA 01772 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES El NO❑
FIXTURFS • FLOORS—a BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND 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 4
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 2
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
WATER PIPING 1
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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND❑
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 Steve gilmore LICENSE 16699 SIGNATURE
MP ElJP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME PLEASANT BAY PLUMBING INC ADDRESS 43 b independence way
CITY Brewster STATE MA ZIP 02631 TEL
FAX CELL EMAIL PLEASNTBAYPLUMBING@COMCAST.NET
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE 0
FEES S PERMIT#
PLAN REVIEW NOTES
...7 rt.7, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
— :�'--I�s�` . ._CA�Y MA DATE 7/sp1;�Z PERMIT# Z 3 - �'/ .� �
,v ju 1 1 2DnBSI E f DDRESS U Tiot �_ Co►,t C OWNER'S NAME I,w
S ei - ADDRESS Sow TEL
FAX
BUILD!PDEPAR
TYPE ftR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL "gc
PRINT
CLEARLY NEW:❑ RENOVATION:VX REPLACEMENT:❑ PLANS SUBMITTED: YES K NO❑
FIXTURES 7 FLOOR-. 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
- - - -
DEDICATED WATER RECYCLE SYSTEM
-
DISHWASHER I
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1.
ROOF DRAIN `
SHOWER STALL ,
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES
WATER PIPING 1
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES WI 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 ❑
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.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tr.- an: - ate •the best of my knowledge
p `
and that all plumbing work and installations performed under the permit issued for this application will be in com Ii.\c=
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. inept provision of the
PLUMBER'S NAME h-�- (�A C_ !LICENSE#I i 36 4i I i' SI6F(ATURE�^
MP K JP ❑ CORPORATION tclit13C-ICI" 'PARTNERSHIP❑#1 I LLC ❑#I
COMPANY NAME I N y iie„��,c u•3 loc , I ADDRESS! t-(-S ( :. . N&ic-ucr.,.>cC CA..),a
CITY! %2C.-k.,>5k-Ct� ISTATEI 1 I ZIP! CILSi ITEL ?74-I -Zz2-t-t.s-s,
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FAX CELLI 'EMAIL' ()�L.'�4v\: 1 ‘ti11vw\CA,
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