HomeMy WebLinkAboutBLDP-25-664 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�<_� CITY West Yarmouth , MA DATE 09/08/2025 PERMIT#,)UbG—Z5-66y
JOBSITE ADDRESS 9 Theodore Roosevelt Rd OWNER'S NAME Bernie McDonald
OWNER ADDRESS[Same as above i TELr781-858-5728 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: , RENOVATION:L REPLACEMENT: PLANS SUBMITTED: YES I NOD
FIXTURES Z FLOOR—. BSM 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES i b, a- ,
WATER PIPING L t I
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Y S i NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Ef O 9 2fl?
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND Li "I JJCf
OWNER'S I URANCE WAIVER:I am aw that the licensee does not have the insurance coverage required by Chapter 142 of the
Massach tts General La , hat signature on this permit application waives this requirement. -1
CHECK ONE ONLY: OWNER AGENT
SIG ATUR 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 'nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Shane Wise I LICENSE#[25556 1 SIGNATURE
MP JP - CORPORATION L,# PARTNERSHIPQ# ILLCQ#
COMPANY NAME Wise Plumbing I ADDRESS 7 Christopher Rd
CITY Waltham STATE MA J ZIP''02451 -1 TEL 617-347-8000
FAX l CELL EMAIL spw@rwsullivan.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND CASFITTERS
ISSUES THE FOLLC+WJING —ICENSE
JOURNEYMAN PLUMBER
SHANE P WISE L z
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7;CHRISTOPHER RD
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WALTHAM,MA<02451-1312 2
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25556 05/01!2126; 616544
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER