HomeMy WebLinkAboutBLDP-21-004588 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
n1-w- , j CITY YARMOUTH MA DATE 2/12/21 PERMIT# BLDP-21-004588
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JOBSITE ADDRESS 33 WOOD RD OWNER'S NAME KNOWLES RICHARD A TRS
P OWNER ADDRESS KNOWLES JUDITH L TRS 123 N POND DR BREWSTER,MA 02631-1929 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ 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 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 1
WATER PIPING 1
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 Gary Thorup LICENSE/90274 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Gary D Thorup ADDRESS 454 S ORLEANS RD
CITY ORLEANS STATE MA ZIP 026534826 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEES$ PERMITS
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
= CITY/TOWN X-411 C,C,774 MA DATE L/</ c:. —/ PERMIT# k3iLDP 21 - p6 1"
JOBSITE ADDRE S 3 /�
�-�� c' OWNER'S NAME
OWNER ADDRESS TEL TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q�
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: LD PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 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/OIUSAND 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
ROOF DRAIN >. _ t -
SHOWER STALL '
SERVICE/MOP SINK i TOILET r r
LI 11:t. 26,
URINAL -_
WASHING MACHINE CONNECTION tit 'i DIN
WATER HEATER ALL TYPES --
WATER PIPING I r
OTHER
INSURANCE COVERAGE: —/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LI" NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEIAN!TY ❑ 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 -st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with alife, •rovision of the
Massachusetts State Plumbing Code and Chapte 42 of the General Laws.
PLUMBE C� �'S NAME � �Y✓( �� LICENSE#/e- ii1_91771 SIGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
•COMPANY NAME /�(�t1l t% Lc:Y1�//lej ADDRESS � 1. , L' J1/YS o
CITY (7; S STATE /> ZIP 6_ TEL'1.56 21/6 173C5
FAX CELL /J�-7C-''/G' EMAIL