HomeMy WebLinkAboutBLDP-18-002392 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 10/22/17k43, PERMIT# BLDP 18 002392
JOBSITE ADDRESS 1420 WEST YARMOUTH RD OWNER'S NAME STONE RICHARD
P OWNER ADDRESS 420 WEST YARMOUTH RD WEST YARMOUTH, MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT: El PLANS SUBMITTED: YES❑ NO El
FIXTURES 1 FLOORS---I 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
WATER PIPING
OTHER 1
OTHER DESCRIPTION: back flow preventer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial 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 El OTHER TYPE OF INDEMNITY El BOND El
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 p'969 SIGNATURE
MP El JP El CORPORATION ❑# 3969 PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Murphy Services Inc ADDRESS 29 Maple Terrace
CITY South Dennis STATE MA ZIP 02660 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
DCD11111T
FEES$ PERMIT#
PLAN REVIEW NOTES