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Home My WebLink AboutBLDP-23-000967 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u .=� �/ CITY YARMOUTH MA DATE 8/23122 J PERMIT# BLDP-23-000967 "� JOBSITE ADDRESS 15 HAYWOOD AVE OWNER'S NAME SMEDLEY KENT B P OWNER ADDRESS SMEDLEY NEUCIMARI B 15 HAYWOOD AVE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL EJ PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO El FIXTURFS 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 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND El OWNER'S INSURANCE VVAIVER: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 Kenneth Thomas LICENSE#1362 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME KENNETH W THOMAS ADDRESS 31 FAIR OAK DR CITY BREWSTER STATE MA ZIP 026312654 TEL FAX CELL EMAIL thomasplumbingheat1@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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK %-..117_1------ ' CITY . 62 .UYbUti l MA DATE [`"J 1;)-c)- a PERMIT# 11 / JOBSITE DDRESS t-L t;1z)d l C S- }vL,:�WNER'S NAME fit �t-v �riwc.( POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2 PRINT �/ CLEARLY NEW: El RENOVATION:L� REPLACEMENT: PLANS SUBMI I I ED: YES ❑ NO❑ FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 5 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 ■■ ■�■■�■�■■■-= DRINKINGFOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN -- INTERCEPTOR(INTERIOR) .1 KITCHEN KITCHEN SINK LAVATORY I ROOF DRAIN � �_ __ I'�,2IIRr '_ SHOWER STALL _ 11■M______I ' V��l_ SERVICE/MOP SINK Ell Bill TOILET I _______I_11NEP 1 iI?1A1_I_ URINAL _____--__MIEN__,■'_ WASHING MACHINE CONNECTION 111ABIENNIONNIMIIII_ WATER HEATER ALL TYPES MMII WATER PIPING _�M ______�� ■ OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑'NO ❑ 1 IF YOU CHECKED YES, PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUT(INSURANCE POUCY 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 1 Massachusetts General Laws, and that my signature on this permit application waives this requirement. - CHECK ONE ONLY: OWNER ❑ AGENT El SIGNATURE OF OWNER OR AGENT Ll 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 cacr pliancwith alj�Fi',ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C f Q LI PLUMBER'S NAME Ks?t�r�E 1�C>N 'c r% L c--'-'� LICENSE# 1 l 4z3 . SIGNATURE MP Lid' JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME-`'in'n'r+S el L.f E (4 ADDRESS -3 1 r-ct_-t i o� f, 1 i� CITY re:2vS r STATE rnot . ZIP ('-,)-C-.) J'I TEL 50 P) In 80_(vc1-4 j FAX CELL EMAIL 'YYIS (EiLi Y1LI f\ec1f 1 yore l'CCM 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