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HomeMy WebLinkAboutBLDP-22-006289 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —, CITY YARMOUTH MA DATE 5/2/22 PERMIT# BLDP-22-006289 l JOBSITE ADDRESS 51 LUMBERJACK TRAIL OWNER'S NAME Luiz Nascimento ] P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL 0 PRINT CLEARLY • NEW:© RENOVATIONS.❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK 1 , TOILET 1 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 Herbert Healis LICENSE30177 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME HERBERT M HEALIS ADDRESS 78 STUDLEY RD CITY S YARMOUTH STATE MA ZIP 026642906 TEL FAX CELL EMAIL hhealis@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES ■ AI- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -.'__ f=_z CITY/TOWN W Yamouth MA DATE 4129/22 PERMIT# 7— 6 "I JOBSITE ADDRESS 51 Lumberjack Trail OWNER'S NAME Nascimento OWNER ADDRESS same TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ® RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ FIXTURES T 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK 1 APR 29 2122 TOILET 1 _ URINAL BUILDING ULPARTME WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I 1 INSURANCE COVERAGE: I have a current IiabilitLinsurance 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 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. 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