HomeMy WebLinkAboutBLDP-20-005338 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
t , -e CITY YARMOUTH MA DATE 4/8/20 PERMIT# BLDP-20-005338
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JOBSITE ADDRESS 24 BRAY FARM RD NORTH OWNER'S NAME LEDUC PHILIP
P OWNER ADDRESS SMYTHE JULIE H 24 BRAY FARM RD NORTH YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES ID NO El
FIXTURES i 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
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER 1 ,
WATER PIPING
OTHER
OTHER DESCRIPTION: / , < '
INSURANCE COVERAGE:
I have a current liability insurance p icy or its substa equivalent which meets the requirements of MGL Ch.142. YES El 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❑ 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 Chris Briggs LICENSEI12901 I SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# LLC ❑# I
COMPANY NAME Chris G Briggs ADDRESS IPO BOX 197
CITY 'CENTERVILLE I STATE IMA I ZIP 1026320197 I TEL I
FAX I I CELL I j G'-- `lCG' " Z S 29 4 EMAIL I
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1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT � 0
FEES$ PERMIT#
PLAN REVIEW NOTES