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HomeMy WebLinkAboutBLDP-18-004569 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK c^r _ CITY YARMOUTH MA DATE 2/13/18 PERMIT# BLDP-18-004569 JOBSITE ADDRESS 52J SOUTH SEA AVE OWNER'S NAME SIMPSON SHAWN G P OWNER ADDRESS 40 RIGDALE RD KINGSTON, MA 02364 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE NO El 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 _ 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 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 111 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 Richard Whiteside LICENSE X969 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# 3969 PARTNERSHIP ❑# LLC ❑# COMPANY NAME Murphy Services Inc ADDRESS 29 Maple Terrace CITY South Dennis STATE MA ZIP 02660 TEL FAX CELL EMAIL RO11C11 P1.1!%11IINC INSPECTION INOTI S BELOW FOR OF11G.USE ONLY F►N:tL►N.SPECT►ON NOTES Yes o THIS APPLICATION SERVE AS THE 111 ocoeerr FEES$ PERMIT# PLAN REVIEW NOTES