HomeMy WebLinkAboutBLDP-20-003736 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
w_ . CITY YARMOUTH MA DATE 1/6/20 PERMIT# BLDP-20-003736
r JOBSITE ADDRESS 67 MERCHANT AVE OWNER'S NAME BRENNAN ELAINE C
P OWNER ADDRESS HAMMOND CHRISTINE L 67 MERCHANT AVE YARMOUTH PORT,MA 02675-2238 fEL
TYPE OR OCCUPANCY TYPE COMMERCIAL I—I RESIDENTIAL n
PRINT
CLEARLY NEW:n RENOVATION:n REPLACEMENT:n PLANS SUBMITTED: YESn NOn
FIXTURES-. FLOORS 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
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. YESn NOn
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITYn BONDn
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 Spencer Hallett LICENSEI45224 SIGNATURE
MP n JP n CORPORATION Eit PARTNERSHIP nk LLC n/
COMPANY NAME Spencer Hallett ADDRESS 18 EASTVIEW TER
CITY MARSTONS MLS STATE MA ZIP 026481372 TEL
FAX CELL EMAIL /
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