HomeMy WebLinkAboutBLDP-20-003912 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
;_=.3iY CITY YARMOUTH MA DATE 1/14/20 PERMIT# BLDP-20-003912
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JOBSITE ADDRESS 21 WEST WOODS VILLAGE OWNER'S NAME ALONG ELINOR C
P OWNER ADDRESS 21 WEST WOODS YARMOUTH PORT, MA 02675-1462 tEL
TYPE OR OCCUPANCY TYPE COMMERCIAL n RESIDENTIAL n
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CLEARLY NEW:[] RENOVATION: pT REPLACEMENT:[] PLANS SUBMITTED: YES[] NOP1
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 1 _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK 1
LAVATORY 1 2
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1 2
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
OTHER 1 .
OTHER DESCRIPTION: Ice Maker
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES pi 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 Wayne Libby LICENSE1552 SIGNATURE
MP n JP [] CORPORATION I PARTNERSHIP 1--I# LLC fit
COMPANY NAME WAYNE R LIBBY ADDRESS 22 BLACKBERRY LN
CITY DENNIS STATE MA ZIP 026382507 TEL
FAX CELL EMAIL
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