HomeMy WebLinkAboutBLDP-20-004403 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 2/11/20 PERMIT# BLDP-20-004403
JOBSITE ADDRESS 17 CAPT YORK RD OWNER'S NAME ENGLAND NANCY A
P OWNER ADDRESS 2012 EAST 131ST ST BIXBY,OK 74008 DEL
TYPE OR OCCUPANCY TYPE COMMERCIAL I I RESIDENTIAL ]i
PRINT
CLEARLY NEW:Ti RENOVATION:] REPLACEMENT:] PLANS SUBMITTED: YES] NOr]
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
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. YESn 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 Stephen Ewing LICENSE1#5281 SIGNATURE
MP n JP Ti CORPORATION I 1# PARTNERSHIP I (# LLC
COMPANY NAME STEPHEN D EWING ADDRESS 140 WHITE MOSS DR
CITY MARSTONS MLS STATE MA ZIP 026481080 TEL
FAX CELL EMAIL