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HomeMy WebLinkAboutBLDP&G-19-002889 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK «I , : CITY YARMOUTH MA DATE 11/12/18 PERMIT# BLDP-19-002889 JOBSITE ADDRESS 27 WREN WAY OWNER'S NAME CONNORS CAROL M TR P OWNER ADDRESS CONNORS FAMILY IRREVOCABLE TRUST 273 NEEDHAM ST TEL DEDHAM, MA 02026 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE NO❑ FIXTURES FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1z 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 1 WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liabilitvinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES❑ NO C_ 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. 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 William Coombs LICENSE#6154 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Pro Plum Inc. DBA Provost ADDRESS 282 Needham St Plumhing Cn CITY Dedham STATE MA ZIP 02026 TEL FAX CELL L EMAIL . .., • uHa rl i I ING WORK ,LL CITY YARMOUTH MA DATE November 12, 2 PERMIT# BLDG-19-002890 = I a JOBSITE ADDRESS 27 WREN WAY OWNER'S NAME CONNORS CAROL M TR G OWNER ADDRESS CONNORS FAMILY IRREVOCABLE TRUST 273 NEEDHAM ST DEDHAM TEL MA 02026 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO[ FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 D NOD IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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-GASFITTER NAME William Coombs LICENSE# 16154 SIGNATURE MP© MGF❑ JP❑ JGFD LPGID CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Pro Plum Inc. DBA Provost Plumbing ADDRESS 282 Needham St, CITY Dedham STATE MA ZIP 02026 TEL FAX CELL EMAIL I