Loading...
HomeMy WebLinkAboutBLDP-21-007469 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 6/22/21 PERMIT# BLDP-21-007469 JOBSITE ADDRESS 110 SOUTH SEA AVE OWNER'S NAME HARRIES ANN LOUISE TRS OWNER ADDRESS ANN-LOUISE HARRIES TRUST 110 SOUTH SEA AVE WEST YARMOUTH,MA TEL 02673 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO Ei FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 1 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❑ 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 LICENSE 301056 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME THEO PLUMBING AND HEATING ADDRESS P.O. Box 397 P.O. Box 397 LLC CITY Centerville STATE MA ZIP 02632 TEL FAX CELL EMAIL theoplumbing@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ El FEES$ PERMIT N PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . 1 l= CITY V"e` 1G✓�e`)"1 MA DATE Co 1 L Li C Z 1 PERMIT#�-6P"Zt-W7k('5 JOBSITE ADDRESS 10 S. S Q� I�l{Q 1 '.P OWNER'S NAME �'''` L-o•)•9 1-1.,/r. E.,15. P « OWNER ADDRESS TEL 5(3SS 7)5- Zo 1-7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IS/----------- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0 FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) = KITCHEN SINK LAVATORY ROOF DRAIN Mt a SHOWER STALL I SERVICE!MOP SINK j TOILET L URINAL WASHING MACHINE CONNECTION i WATER HEATER ALL TYPES 1 e WATER PIPING �___t._._....:. OTHER I - / INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES lNO ❑ IF YOU CHECKED YES, PLEASE INDICATE E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY OTHER TYPE OF INDEMNITY El BOND El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit ap?lication waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT1•1 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 Ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 1\ ,Yt'1661 Ct'N'e6" ''•a`S LICENSE# i>l- 5'9.O_S.6 7" SIGNATURE MP❑ JP LY' CORPORATION❑# PARTNERSHIP❑.# LLC�# C30I 3cc;ei 32 COMPANY NAME 'T \4c? Q( tij, o O ISe‘,k'/' DDRESS [ •O lnjp < 'Gt' , CITY Ce`\K/V`I S e STATE tt\-, ZIP 62 6 3 Z TEL cog1-) 6 - j6 l FAX CELL 1J EMAIL tk€o 0-v--' v),,, l L-,G a. cc----, • l ;PAS 1•-•F—T7/-- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES