HomeMy WebLinkAboutBLDP-21-005544 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
4 CITY YARMOUTH MA DATE 3/25/21 PERMIT# BLDP-21-005544
Fiw JOBSITE ADDRESS 227 WOOD RD OWNER'S NAME WHITTEMORE ERIN M
D OWNER ADDRESS 227 WOOD ROAD SOUTH YARMOUTH,MA 02664 —1 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
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CLEARLY NEW: ❑ RENOVATION:E 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
. _
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 E 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 cannon LICENSE 13414 SIGNATURE
MP ❑ JP E CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS winchester
CITY bourne STATE MA ZIP 02532 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
/ZI /'//')n, THIS APPLICATION SERVE AS THE PERMIT El El
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