HomeMy WebLinkAboutBLDP-21-006877 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- . CITY YARMOUTH MA DATE 5/25/21 PERMIT# BLDP-21-006877
JOBSITE ADDRESS 33 NEARMEADOWS RD OWNER'S NAME STEPHENSON ANNE D TRS
P OWNER ADDRESS NEARMEADOWS ROAD REALTY TRUST 34 GALE RD SWAMPSCOTT,MA 01907 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL ❑
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CLEARLY NEW: ❑ RENOVATION:0 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 1
SERVICE/MOP SINK
TOILET _
URINAL _
WASHING MACHINE CONNECTION _
WATER HEATER
WATER PIPING
OTHER 1
OTHER DESCRIPTION: shower drain on 1st floor
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 Jeffrey Krula LICENSE kffrey Krula SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Bath Fitter ADDRESS 25 Turnpike Street
CITY West Bridgewater STATE MA ZIP 02379 TEL 5085212700
FAX CELL 5087287718 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEESS PERMITS
PLAN REVIEW NOTES