HomeMy WebLinkAboutBLDP-21-007545 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 6/28/21 PERMIT# BLDP-21-007545
JOBSITE ADDRESS 36 PEQUOD CIR OWNER'S NAME KELLEY DAVID J
P OWNER ADDRESS KELLEY ANN M 36 PEQUOD CIR YARMOUTH PORT,MA 02675-1918 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
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CLEARLY NEW: ❑ RENOVATION,❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURES FLOORS—+ BSM 1 2 3 4 5 6 7 8 _ 9 10 11 12 13 14
BATHTUB _ 1 _
CROSS CONNECTION DEVICE 0 _ _
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 2 �—
ROOF DRAIN ____
SHOWER STALL 1 _
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 0 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.
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 Fernando Coelho LICENSE 3K1508 SIGNATURE
MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 16 Wildwood Path
CITY West Yarmouth STATE MA ZIP 02673 TEL
FAX CELL EMAIL fernando252c@gmail.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑
FEES$ PERMITS
PLAN REVIEW NOTES