HomeMy WebLinkAboutBLDP-23-005488 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY EARMOUTH MA DATE 4/4/23 PERMIT# BLDP-23-005488
JOBSITE ADDRESS 50 LONG POND DR OWNER'S NAME DUMONT DONALD A TR
P OWNER ADDRESS DUMONT COMMERCIAL REALTY TRUST 642 MINGO LOOP RD RANGELEY,ME TEL
04970
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
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 s `~
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _ _
KITCHEN SINK
LAVATORY 4
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK
TOILET 4
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. YES❑ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND 0
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 signatLre 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.
PLUMBERS NAME John Downey LICENSE 312070 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 37 Bray Farm Road North
CITY 'Yarmouth Port I STATE IMA -I ZIP 026751551 TEL
FAX I I CELL I I EMAIL I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PE MIT TO PERFORM PLUMBING WORK
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—t--: CITY 1 4esIrnUv 1' 1 MA DATE v1 `I / 3 P Rd - 2 Ub sygS-"
JOBSITEADDRESS SZ L-,/It4 1-lIn) D i. OWNER'S NAME
POWNER ADDRESS IPc'✓I D Li-riverr TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL D.
PRINT
CLEARLY NEW: ❑ RENOVATION: ISi, REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE '
DEDICATED SPECIAL WASTE SYSTEM 1
DEDICATED GASIOILSAND SYSTEM
DEDICATED GREASE SYSTEM ,
DEDICATED GRAY WATER SYSTEM r '
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER '
FLOOR I AREA DRAIN I ,
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 7 ,
ROOF DRAIN I t
SHOWER STALL
SERVICE I MOP SINK '
TOILET ,
URINAL
. WASHING MACHINE CONNECTION '
WATER HEATER ALL TYPES
WATER PIPING _ _
OTHER
'
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 R OTHER TfPE OF INDEMNITY ❑ BOND (11
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1' Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
L&A 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. ��
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PLUMBER'S NAME LICENSE# SIGNATURE-
MP❑ JP E2 CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Jc)inn P----wne, ADDRESS 1 Y'' kj,
G ? TEL .3`'0- 4 Z) -5 GS 7
CITY ` ov iry i fc r/ STATE >�•� ZIP
FAX CELL EMAIL J fie-I,;. tL 1 i1J - c c='ri
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