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Home My WebLink AboutBLDP-23-005587 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i (? CITY YARMOUTH L,A MA DATE 4/7/23 PERMIT# BLDP 23 005587 r JOBSITE ADDRESS 444 ROUTE 28 OWNER'S NAME SAMUELS REALTY CO INC P OWNER ADDRESS IPOLO CENTER 678 AQUIDNECK AVE MIDDLETOWN,RI 02842 TEL TYPE OR OCCUPANCY TYPE COMMERC AL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ 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 VVATER 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 2 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 Robert Wilson LICENSE 21338 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ROBERT WILSON ADDRESS 50 LAKE RD CITY WEST YARMOUTH STATE MA ZIP 026733743 TEL FAX CELL EMAIL willidog50@icloud.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -- /�( �j `-__1_i= CITY Vie S7 �{It11U.7 MA DATE 11 7 �},c'4 PLRMlset 2 --7 00 5 ?7 JOBSITE ADDRESS LJL/Li 127 ,.)- 5"- OWNERS NAME i_:.___V____Z_____L___C't l' G{�� POWNER ADDRESS TEL FAX TYPE OR OCCUPANC TYPE COMMERCIAL[V EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES T FLOOR-4 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 1 AREA DRAIN INTERCEPTOR(INTERIOR) Ft E v KITCHEN SINK ,,, u LAVATORY • ' >f ROOF DRAIN APR LULJ , F SHOWER STALL —' SERVICE/MOP SINK •LB:JILDIING TOILET DhHARTN ENT URINAL 1-- t- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING OTHER (� t/l/�t lrC{c L I� 1�� - ( i'f�� .Ch, 1 /Lv,; n ,ECG A./ icVc/1-7e1l . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES T40 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE E 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 it Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1�1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in liar withyrtinent provision of the Massachusetts State Plumbing Code an PLUMBER'S NAME Oh (, Chap 142 of the General Laws. 1,� i � ✓( /1 LICENSE ft- SIGNATURE MP(11 JP 1 CORPORATION❑# PARTNERSHIP❑#/ LLC❑# COMPANY NAME )( S ()71"411)/1 _ rt I /l{ 1-4:471°S ADDRESS S �� J G SS g vi 1i CITY )CT\P(S STATE PIA ZIP 1)�t"�0---- TE FAX CELL l( XIS 't7I EMAIL tiV(//161. S v Irk jClaud'Ca(-1( ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT It PLAN REVIEW NOTES