HomeMy WebLinkAboutBLDP-22-002021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
yr, CITY [YARMOUTH MA DATE 10/8/21 PERMIT# BLDP-22-002021
1 JOBSITE ADDRESS 108 POINSETTIA DR OWNER'S NAME STANLEY THOMAS M
P OWNER ADDRESS C/O THOMAS STANLEY 19 NEIGHBORS LN WALTHAM,MA 02453 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
FIXTIIRFS 1 FLOORS RSM 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
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 0 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 David Houde LICENSE 1:6673 SIGNATURE
MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME !McDonnell Mechanical Services Inc I ADDRESS 179 School Street
CITY West Dennis STATE MA ZIP 102670 TEL 5083940005
FAX I CELL 5082463152 EMAIL I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE 0
rk1-1,5 BIT
FEES$ PERMIT#
PLAN REVIEW NOTES