HomeMy WebLinkAboutBLDP-23-005196 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
� CITY YARMOUTH MA DATE 3/21/23 PERMIT# BLDP-23-005196
) JOBSITE ADDRESS 22 HOLLY LN OWNER'S NAME EGAN JAMES M
r'T.st'
P OWNER ADDRESS EGAN KRISTA M 81 GROVE ST HOPKINTON,MA 01748 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURES I FLOORS BEM 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 1
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 James Bertino LICENSE 112033 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME IJAMES P BERTINO ADDRESS 60 TELLER DR
CITY ASHLAND STATE MA ZIP 017211061 TEL
FAX CELL EMAIL james.bertino@gmail.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE
FEES$ PERMIT#
PLAN REVIEW NOTES
-1; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
. ,cYpi uth MA DATE 3/21/23 PERMIT# •P
22 Holly Lane Jim Egan
JOBSITE DRESS OWNER'S NAME
__ 1 2wg4D22 Holly Lane TEL FAX
BUILDING EPq
_jr (PE OR uu C TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT"'
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:] PLANS SUBMITTED: YES❑ NO 0
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/OIL/SAND 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 ,
SHOWER STALL
SERVICE/MOP SINK
TOILET _
URINAL _
WASHING MACHINE CONNECTION V
WATER HEA I ER 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 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 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massa a ene ws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT
SIG TU OF OWNER OR AGENT
I y 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" complia with 'nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,
PLUMBER'S NAME LICENSE# 12033 GNATURE
MP El JP 0 CORPORATION❑# PARTNERSHIP 0# LLC❑#
James Bertino Plumbing60 Teller Drive
COMPANY NAME ADDRESS
CITY Ashland STATE MA ZIP 01721 TEL 508-989-0754
FAX CELL EMAIL james.bertino@gmail.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