Loading...
HomeMy WebLinkAboutBLDP-22-001609 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i c CITY YARMOUTH —1 MA DATE 9/21/21 PERMIT# BLDP-22-001609 JOBSITE ADDRESS 30 CREST CIR OWNER'S NAME David Palmer P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑ FIXTURES I 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 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 El NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El BOND El 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 F'lumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Edward Mathews LICENSE 16180 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME [EDWARD J MATHEWS ADDRESS 24 WOODCREST DR CITY MELROSE STATE MA ] ZIP 021763414 TEL FAX 7 CELL EMAIL ed_matthews9@hotmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE FEES$ PERMIT R PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _�- CITY V c-An V\ MA DATE Cri 1 11 PERMI # - 2-7— 11009 JOBS ITE ADDRESS 0 l i cc CAl r OWNER'S NAME R I ''Ac r POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL k PRINT CLEARLY NEW:t3 RENOVATION:❑ REPLACEMEN PLANS SUBMITTED: YES 0 NO❑ FIXTURES Z 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 % - �V DRINKING FOUNTAIN , FOOD DISPOSER FLOOR I AREA DRAIN _ , INTERCEPTOR(INTERIOR) . KITCHEN SINK LAVATORY , ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL 1 . 1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER 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 N 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 0 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — PLUMBER'S NAME inAV"-r LICENSE# /S/ SIGNATURE MPP JP 0 lI CORPOR�ATION ip# PARTNERSHIP❑# LLC # >�Gf'1)ev- en);- /'lVn'1,Jf ADDRESS �rzoQCre COMPANY NAMEI�l CITY / "L" STATE Mil ZIP TEL 7-17 TEL /2 ? �/ s? /