HomeMy WebLinkAboutBLDP-22-004421 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH 1 MA DATE 2/8/22 PERMIT# BLDP-22-004421
JOBSITE ADDRESS 9 GRANT RD OWNER'S NAME BILLMAIR STACEY L
P OWNER ADDRESS 9 GRANT RD WEST YARMOLTH,MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURFS • FLOORS—+ BStM1 1 2 3 4 5 6 7 8 9 10 11 1? 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/011-/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
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 0
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 Matthew Hyland LICENSE 33776 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME MATTHEW HYLAND ADDRESS 127 COPELAND ST
CITY BROCKTON STATE MA ZIP 023016958 TEL
FAX CELL EMAIL hylandhvac@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
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r� CITY AQ>M �� _ MA DATE - )- PERMIT# 1' -— (-1 414
JOBSITE ADDRESS 6 /� A) , �_ M_. OWNER'S NAME ST&Q
Pt OWNER ADDRESS El 1 BLS��" S7, ,._, ..0-- FAX _ .
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL I _,I RESIDENTIAL[]
PRINT
CLEARLY NEW: D RENOVATION: REPLACEMENT: \" PLANS SUBMITTED: YES E. NO
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FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
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CROSS CONNECTION DEVICE
_, - "- `. s-.. i ! _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM I
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER .. ;� • :.
-- -
DRINKING FOUNTAIN �+�-. .� I -- --
FOOD DISPOSER —z i;� ___. _ �_ _
FLOOR I AREA DRAIN I i
INTERCEPTOR (INTERIOR) ,_,
KITCHEN SINK s �._«. Jib
LAVATORY _.
___. _.
ROOF DRAIN I
-
11
SHOWER STALL f ,111111
1734.111
SERVICE I MOP SINK 111Magit*d
TOILET .
��URINAL -- :^ 0111
WASHING MACHINE CONNECTION MEIMMEM l � =
WATER HEATER ALL TYPES WO T _g I=r:- 'a
WATER PIP NG OM ;:ww..
OTHER - 1 Qjz„ $ affilliliM IIIIIIMOINITIWOMMINIMIN
i 11111111111111111111111111M11.1.1111111111111111111111111111111111
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INSURANCE COVERAGE:
l 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 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.
CHECK ONE ONLY: OWNER AGENT L i
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 an acc a to the best of my knowledge
and that ail plumbing work and installations performed under the permit issued for this application will be in compli e it Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME ANtirVkL4 Mi.AA! i . ._.. _ __ . 3 LICENSE # 33.2 7(4, SIGNATURE
MP JP CORPORATION #r _PARTNERSHIP J#[ ILLCU#r
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COMPANY NAME eft A \ UAL _.�_ ,- ADDRESS i 3?, C o�l - _ i
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CITY rvboc4, _ �. �_._, �' STATE Lv\r\ j ZIP [ Oa3 TEL I- _Co S6 7(FC,. _ _ I
FAX E CELL . EMAIL MA() �__...- ._� t\//A L .� G Mti GC, •• C�ram
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