HomeMy WebLinkAboutBLDP-23-005628 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�� _/ CITY YARMOUTH MA DATE 4/10/23 PERMIT# BLDP 23 005628
II JOBSITE ADDRESS 79 ELDRIDGE RD OWNER'S NAME COUTURE ELAINE M TR
P OWNER ADDRESS 11 SEAVIEW DR KINGSTON 02364-0000 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO El
FIXTURES i FLOORS--+ BSM 1 2 3 4 5 6 7 8 9 . 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
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
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❑ 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❑ 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.
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 Robert Heaney LICENSE 32219 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ROBERT L HEANEY ADDRESS 33 RICHARD DR
CITY HANOVER STATE MA ZIP 023392537 TEL
FAX CELL EMAIL rheaneyl@yahoo.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMITS
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1 'JrEfk �` •,11/1/ �r 3 -S 7 .
r � � �) f, MA DATE It► '•��� "` '� �,�PER I( Z 16
1 Q SITE DRESS ! �O r i d�9 ( OWNER'S NAME 1 G�ti 01Ur e
OWNER DID ESS l ) JAR (), e�.c/ r- ;, Td'� E-Cc>✓(hh aC I ,
_� _ � � TEL l� FAX
DE ARTMENT
BB 1 QM_ �CCUP TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO '
FIXTURES 1 FLOOR-» Km 1 2 3 4 5 6 7 8 9 10 11 12 13 14 -I
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 y
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _1
KITCHEN SINK '
LAVATORY "
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
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 0 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 0 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 Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER El AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicatio r rue-and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will in ,p ce wi aN erti t rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,_Q/� j
PLUMBER'S NAME "d h e r-j V1'Cp-n.R`1 LICENSE#3` Ja- 19 " 11� SIGNATURE
MP 0 JP, J CORPORATION 0# PARTNERSHIP # LLC 0#
COMPANY NAME \NG -9e f HyADDRESS
3 rC[La-,d Dr-
.
CITY 1 1 :.-t/ STATE' / ili ZIP 0`) 3 37 TEL )irl -7 )5 7 i 3
FAX CELL EMAIL h 'e 0, \j ) 5/ /
/ 6cJ