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Home My WebLink AboutBLDP-23-005975 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/27/23 PERMIT# BLDP-23-005975 ra- JOBSITE ADDRESS 16 ANDRINA RD OWNER'S NAME BALCOM KEVIN A P OWNER ADDRESS BALCOM KATHLEEN M 810 ADAMS ST HOLLISTON,MA 01748 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO FIXTURFS 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 WATER PIPING 1 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 Ryan White LICENSE 1068 SIGNATURE MP D JP ❑ CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME WHITE PLUMBING AND HEATING ADDRESS IPO box 425 CITY Harwich STATE IMA I ZIP 1026450000 I TEL 15082467375 FAX I I CELL I I EMAIL I I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK (AG 4(i't 1" -Z7 -Z R_ECEIVE1 -:==){W�' CITY MA DATE 3 PERMIT _ ___ - _.._ JOBSITE ADDRESS 16) Ail(,{f;nt( OWNERS NAME aq l o M APR 2 7 2i123- POWNER ADDRESS TEL FAX . r3 ILUINv ut( 11 MEN TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL v _ - PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMI(I ED: YES ❑ NO❑ FIXTURES T FLOOR-+ 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 SYSTEM L. DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER — FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 I . I ROOF DRAIN SHOWER STALL i SERVICE/MOP SINK I TOILET I — URINAL . j WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES 1 WATER PIPING OTHER - j - i INSURANCE COVERAGE: ,_,�,� I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ifs' NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 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 l' Massachusetts General Laws, and that my signature on this permit application waives this requirement. T ,-- CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT L',.I 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 I Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME 1 .. wL. LICENSE#A o6 g-(4. / SIGNATURE MP JP❑ CORPORATION ❑# PARTNERSHIP❑.# LLC El# COMPANY NAME 1/-/L' P� ADDRESS Iry �01< K 2S CITY 1�c,..)7 STATE AO— ZIP 0 ZG Yr TEL 5-C1- 2qk 7 37S FAX CELL EMAIL ChA/1 Je /0/1g l 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