HomeMy WebLinkAboutBLDP-18-005558 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
>5 4, '( CITY YARMOUTH ] MA DATE 4/5/18 PERMIT# BLDP-18-005558
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<< =�=`` � JOBSITE ADDRESS 36 MAINE AVE OWNER'S NAME TEDESCO ROBERT J TRS
P OWNER ADDRESS TEDESCO NANCY A TRS 32 WINFIELD ST DEDHAM. MA 02026 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YESE NO El
FIXTURES 1 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 1
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
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 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 Andrews Hayes LICENSE#6489 SIGNATURE
MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ANDREWS C HAYES ADDRESS 22 RUSTIC LN
CITY HYANNIS STATE MA ZIP 026014340 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑
DC DIIIIIT
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
CITY t")ts 7c -m a v i� MA DATE ilk, A PERMIT#saio /a 66 6%4
JOBSITE ADDRESS 34 ham. h 40( OWNER'S NAME XI 54a
OWNER ADDRESS 3G N a4w 11,4_ TEL? /9-6" 3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL NJ
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR—F BSM 1 2 3 4 5 6 7 B 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 SYSTEM
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
i WATER HEATER ALL TYPES
WATER PIPING
OTHER
i -
INSURANCE COVERAGE: —/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES L NO 0
I 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.
rr
r= CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
Li 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 Ah H04..r LICENSE# I4 4V _ SIGNATURE
MP d JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME PLUMS-h1 Sb!(ykatis I3, Nwj}Cc ADDRESS 72
CITY 111 S STATE AN- ZIP 6-2,40/ TEL
FAX CELL .2-1/- 2h— fat 3 EMAILpIu/4 — brtc 11/0 7a1•ob.ca/M
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