HomeMy WebLinkAboutBLDP-22-001854 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
rpr; CITY YARMOUTH MA DATE 10/2/21 PERMIT# BLDP-22-001854
JOBSITE ADDRESS 12 MOHEGAN LN OWNER'S NAME DIAMOND DISTRICT RLTY LLC
P OWNER ADDRESS C/O DEVENDORF BRIAN 11 GOOSENECK LN SWAMPSCOTT,MA 01907 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑''
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURFS FLOORS RSM 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 2
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER 1
WATER PIPING
OTHER 1 2
OTHER DESCRIPTION: 1st Floor
Pot Filler
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❑ BOND❑
OWNER'S INSURANCE yVAIVER: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 Stale Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Michael Grillo LICENSE IAA SIGNATURE
MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Thonus North PHAC ADDRESS 12 Mohegan Lane
CITY Yarmouth Port STATE MA _ I ZIP 02675 TEL 7745215698
FAX CE'_L EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ El
FEES$ PERMIT S
PLAN REVIEW NOTES