Loading...
HomeMy WebLinkAboutBLDP-17-03372 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ii;it= --wlw CITY SOUTH YARMOUTH i MA DATE 10/20/16 PERMIT#ffi-0)'/7'--001/7 JOBSITE ADDRESS 1.12 LAKEFIELD ROAD I OWNER'S NAME OMERZU POWNER ADDRESS L2 LAKEFIELD ROAD TELE08-280-4587 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:[�, PLANS SUBMITTED: YES r-1 NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB R R 1 0 0 — —TT-- CROSS CONNECTION DEVICE ff DEDICATED SPECIAL WASTE SYSTEM __ DEDICATED GAS/OIUSAND SYSTEM __1,__ -` _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I' r DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN _ __ INTERCEPTOR(INTERIOR) )_ KITCHEN SINK j; LAVATORY _ r ROOF DRAIN ' SHOWER STALL SERVICE/MOP SINK TOILET J URINAL _i 1 r WASHING MACHINE CONNECTION It J WATER HEATER ALL TYPES 1 I ___I,._._ __ WATER PIPING OTHER 4 _I,________,, ._1i i1__ _ii I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES i NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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. CHECK ONE ONLY: OWNER AGENT 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 a ate 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 all Pe nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME MARK MORAN LICENSE# 20786 _1 SIGNATUR MP JP L] CORPORATION j#1 IPARTNERSHIPLI#r LC Li# COMPANY NAME L MORAN PLUMBING&HEATING ADDRESS 16 BRAMBLEBUSH DRIVE CITYLFORESTDALE STATE MA I ZIP 102644 TEL 508-648-2934 FAX ! CELL 508-648-2934 EMAIL MORANPANDH@GMAIL.COM I L P%j_ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES