HomeMy WebLinkAboutBLDP-23-005584�. _
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- ffir� CITY YARMOUTH MA DATE 4/7/23 PERMIT# BLDP-23-005584
rs JOBSITE ADDRESS 233 PLEASANT ST OWNER'S NAME GRIMES THOMAS A
P OWNER ADDRESS C/O STAGER NANCY H&JAMES E 233 PLEASANT ST SOUTH YARMOUTH,MA TEL
02664
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:0 REPLACEMENT:D PLANS SUBMITTED: YES NO❑
FIXTURES t 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
SERVICE/MOP SINK
TOILET _ 1
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 El NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY 0 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 Michael Pasic LICENSE 11512 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 60 Clamshell Point Lane
CITY Cotuit STATE MA ZIP 02635 TEL
FAX CELL 7748367804 EMAIL
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
-�� � I
=1_f=> CITY 1)A� MA DATE'N�1v PERMIT#731-a)--Z3'UOZe
JOBSITE ADDRESS �� i�j, 'j� OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDE
PRINT
CLEARLY ›VgrNE3r RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 ' 9 I 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL -
SERVICE/MOP SINK '
TOILET
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER $� ,
17 Sim1S. r _
INSURANCE COVERAGE:I
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL- . NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLle,10R, OTHER TYPE OF INDEMNITY 0 BOND 0
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
LLI I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in om.to t all Pertine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
41
PLUMBER'S NAME \`LICENSE# SIGNATURE
MI;DEbJP❑ 'f CORPORATION❑# NERSHIP❑.# LLC❑#
COMPANY NAME V A • •(-11S;c.,Q 4 ADDRESS f . V
CITY C� ll.s,, i � ' /� . � ,
STATBftj Lk . ZIP O TEE? )'-I v
FAX CELL EMAIL V(k l r)LAY. c ly 1
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