HomeMy WebLinkAboutBLDP-17-006490 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
VT-'vies CITY YARMOUTH MA DATE 6/13/17 PERMIT# BLDP-17-006490
JOBSITE ADDRESS 1 CRICKET LN OWNER'S NAME ROBERTSON CARROLL E
P OWNER ADDRESS 27 COSBY AVE AMHERST, MA 01002 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: 0 RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
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
WATER PIPING
OTHER 1
OTHER DESCRIPTION: Outside wash station
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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.
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 Anthony Cooper LICENSE p2048 SIGNATURE
MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ANTHONY J COOPER ADDRESS 66 CHUCKLES WAY
CITY MARSTONS MLS STATE MA ZIP 026481583 TEL
FAX CELL EMAIL
ROl GII I'I.I \WING INSI'I(I ION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
les No
THIS APPLICATION SERVE AS THE ❑
DC DIIAIT
FEES$ PERMIT#
PLAN REVIEW NOTES