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HomeMy WebLinkAboutBLDP-21-007582 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Rsi CITY YARMOUTH MA DATE 6/29/21 PERMIT# BLDP-21-007582 174, JOBSITE ADDRESS 40 HEADWATERS DR OWNER'S NAME Stephen A Winslow P OWNER ADDRESS MA 02653 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 1 INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 1 1 3 ROOF DRAIN SHOWER STALL 1 1 SERVICE/MOP SINK TOILET 1 1 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 WATER PIPING 1 OTHER 1 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El 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 Stephen Winslow LICENSE V298 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME STEPHEN A WINSLOW ADDRESS 18 REARDON CIR CITY IS YARMOUTH STATE (MA I ZIP 1026641207 I TEL I FAX I I CELL 1 I EMAIL linspections@efwinslow,com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE.USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT � ❑ FEES$ PERMIT# PLAN REVIEW NOTES