HomeMy WebLinkAboutBLDP-18-002320 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 10/12/17 PERMIT# BLDP-18-002320
JOBSITE ADDRESS 414 LONG POND DR OWNER'S NAME HOLMES WALTER
P OWNER ADDRESS HOLMES PATRICIA A 414 LONG POND DR SOUTH YARMOUTH,MA TEL
02664-4244
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:El 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
WATER PIPING
OTHER 1
OTHER DESCRIPTION:Hook up indoor septic to new outdoor septic line
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 El 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 Richard Olsen LICENSE X166 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP❑# LLC ❑#
COMPANY NAME THE HOKUM ROCK CORP ADDRESS PO Box 2026,357 Hokum Rock Rd
CITY Dennis STATE MA ZIP 02638 TEL 5083855290
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
DCDUIT
FEES$ PERMIT#
PLAN REVIEW NOTES