HomeMy WebLinkAboutBLDP-23-004891 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
J..-, CITY YARMOUTH MA DATE 3/7123 PERMIT# BLDP-23-004891
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JOBSITE ADDRESS 938 ROUTE 6A OWNERS NAME 011ie Ormon
P OWNER ADDRESS 938 MAIN ST YARMOUTH PORT,MA 02675-2172 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 1
_ROOF DRAIN
SHOWER STALL _ _ 1
SERVICE/MOP SINK _ _
TOILET _ _ 1 _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER 1 _
WATER PIPING 1
OTHER _ T_ _
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 111 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
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 Kevin McCullough LICENSE Massachusetts SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 91 Governor Bradford
CITY Brewster STATE MA ZIP 026310000 TEL 5088961962
FAX CELL 7747222953 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES