HomeMy WebLinkAboutBLDP-22-004419 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 2/8/22 PERMIT# BLDP-22-004419
r JOBSITE ADDRESS 16 MARGARET JOSEPH RD OWNER'S NAME JOLLEY ELLEN M
P OWNER ADDRESS 16 MARGARET JOSEPH ROAD YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL CI RESIDENTIAL ❑
PRINT
CLEARLY NEW❑ 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 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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
OTHER DESCRIPTION:
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.
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 Matthew Hyland LICENSE 16776 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME MATTHEW HYLAND ADDRESS 127 COPELAND ST
CITY BROCKTON STATE MA ZIP 023016958 TEL
FAX CELL I I EMAIL hylandhvac@gmail.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE El ❑
FEES S PERMIT#
PLAN REVIEW NOTES
1. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
--s„ ' j3 CITY li/2,Mop T!_ ...__ Po RI- MA DATE 2- ? ) 1 PERMIT# Z1_ - 4(11 )
JOBSITE ADDRESS OWNER'S NAMER
,() A e,) ---- ._:,_ ._ _ , .__. _ .__ I
OWNER ADDRESS TEL- -7 76 C.V, IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL O. RESIDENTIALr4
PRINT
CLEARLY NEW: Q RENOVATION: '.1] REPLACEMENT: X, PLANS SUBMITTED: YES ID NO[;'
FIXTURES I FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB -
_ _ �.�i`_� _ - = - _: .- a —�-_
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM � v
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM I _
DEDICATED GRAY WATER SYSTEM ___ _
DEDICATED WATER RECYCLE SYSTEM �_ .
DISHWASHER •
DRINKING FOUNTAIN . - - -. '. c
FOOD DISPOSER ';_,
FLOOR / AREA DRAIN �'��
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY ,�.: ��. �;� . ._� . ,-�.. � --
I
ROOF DRAIN _., I Ij—.4 , .- .
-
SHOWER STALL I
SERVICE l MOP SINK
TOILET i I _+estr.
URINAL ,, •
WASHING MACHINE CONNECTION I. _ 1. 4 i ,„
tl . _ `y
WATER HEATER ALL TYPES 1 _. ii.- —L.
_ _ i;.
WATER PIPING 1
. .__ . ,/B y.
[ Acci ;‘
� E;t1i^GI i �.
OTHER � pa ,,,A4._._, l _
- __ r:.
fir. : ..-
INSURANCE COVERAGE:
l have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES /NO 0
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 are true an acc a ' to the best of my knowledge
and that ail plumbing work and installations performed under the permit issued for this application will be in compli e it Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME P; (1�„ I.„VI L.A t.}__w..._.___.�.�._.. ..__ ._ j LICENSE # 33 7.74J SIGNATURE
MP JP CORPORATION #t 1PARTNERSHIPL # LLCLJ#
COMPANY NAME �� A AA \jAC. LCD-, �,.. -.�_. .�- ADDRESSCo ...,.�� Qn.. . , _ __ ___
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CITY L N30t, L\, I STATE rivviT j ZIP 175.3 Ca TEL - 6 (^ _ _ 6
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FAX CELL I EMAIL 1 PL/1,1) L\ VAC G/ M t L . co,,,A, -, _._ _ . . . . .
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