HomeMy WebLinkAboutBLDP-16-004546 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Isq# CITY YARMOUTH MA DATE 2/5/2016 PERMIT#� P GAG�/SIIE'
� 29 VALLEY ROAD EDWARD PARKER
JOBSITE ADDRESS OWNER'S NAME
OWNER ADDRESS TEL 508 775 2006 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑■ 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
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
WATER HEATER ALL TYPES
WATER PIPING 1
OTHER
RAISE DRAINS FOR NEW SEPTIC 1
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 ❑■ 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 a e true and accur to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c liance with I P rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME DOUG LANGTRY LICENSE# 11305 SI ATURE
MP ■❑ JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑■ # 3081
COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1268 ROUTE 28
CITY SOUTH YARMOUTH STATE MA ZIP 02664
TEL 774-470-1350
FAX 774-470-1350 CELL EMAIL DOUG-AQUA@COMCAST.NET
Z-0 I
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