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Home My WebLink AboutBLDP-23-005377 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .e CITY YARMOUTH MA DATE 3/30/23 PERMIT# BLDP-23-005377 JOBSITE ADDRESS 35 KNOLLWOOD DR OWNERS NAME DANIEL CHISOLM P OWNER ADDRESS TINA CHISOLM 35 KNOLLWOOD DR YARMOUTH PORT 02675-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESD NO❑ FIXTURES l 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 1 _ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING 1 OTHER 2 3 1 OTHER DESCRIPTION: 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 El 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 Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Daniel Chisholm LICENSE'41659 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME DANIEL J CHISHOLM ADDRESS 35 Knollwood Drive CITY Yarmouth Port STATE MA ZIP 02675-0000 TEL FAX CELL EMAIL dachisholm1990@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ El FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 10 CITY_ /<t/ 1'l it,� / Lift MA DAT 3 j() °` .3 PE IT#P 3 -G'� �33 77 JOBSITE ADDRESS c7`��t feI/} Cl / • OWNER'S NAME / c7iJi t� �rl j,S�6�2 POWNER ADDRESS JCr?iv/e TEL 7 c1/- 4'/-/ •/-57 f AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:IV REPLACEMENT:V PLANS SUBMITTED: YES[2' NO❑ FIXTURES Z FLOOR—+ BSIJM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _______ I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 1 DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ - DRINKING FOUNTAIN FOOD DISPOSER FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I T ROOF DRAIN R E v E u • F SHOWER STALL �---- �. SERVICE!MOP SINK TOILET 3_ MAR 3- (2q URINAL ' WASHING MACHINE CONNECTION BJILUINL utNVK i M NT I' WATER HEATER ALL TYPES - WATER PIPING OTHER .4-CC' )/a_/ft-r INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO L 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 ' Mass�ehusetts d thatfen ral Laws, y nature on this permit application waives this requirement. T /L1/.I/f/ CHECK ONE ONLY: OWNER GENT ❑ jx GNATURE OF OWNER OR AGENT 1 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 knowle ge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with ertin t rovisio of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' /1 2 2-1 PLUMBER'S NAME LICENSE# / /(, 5-9 SIGNATURE MP Eir---JP❑ CORPORATION❑# PARTNERSHIP❑.# LLCy# COMPANY NAME J / f / 0 4 s i 0/iv, ADDRESS 35 L72(,/L//66/ r CITY i IzW i / STATE A. ZIP CV-4 75 TEL 7 /-V -?.?1/.7 FAX CELL7t'/ IV--/ -9 3`'_3 EMAIL c //7c—ips iti/in / 96k' n>«./('c1,),� 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 I