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Home My WebLink AboutBLDP-22-00677818 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 5/20/22 PERMIT# BLDP-22-006718 rm JOBSITE ADDRESS 528 FOREST RD OWNER'S NAME TOWN OF YARMOUTH SENIOR CTR P OWNER ADDRESS 1146 ROUTE 28 SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO 0 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 ROOF DRAIN SHOWER STALL _ • SERVICE/MOP SINK TOILET URINAL 6 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 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 Christopher Keith LICENSE L6690 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME KEITH BROTHERS PLUMBING, ADDRESS 19 Milford Street CITY Plymouth SIAID IMA I ZIP 02360 TEL I5083178577 FAX CELL EMAIL stevie@keithbros.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Mi ___ CITY yti-gem o v-fq MA DATE � Z °Z Z PERMIT# JOBSITE ADDRESS S Z 2 /Q - d--,; 1C0. €✓ Y r-•i,OWNER'S NAME 0- ec-...r OWNER ADDRESS 7`r* IiL,,,,2 o TEL 5V-3<7-LS 77 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT- PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 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 1 AREA DRAIN R INTERCEPTOR(INTERIOR) KITCHEN SINK I LAVATORY 1 8 2022 ROOF DRAIN SHOWER STALL • SERVICE/MOP SINK at.ILDING DE -31 1 TOILET URINAL 6 , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES —" WATER PIPING I OTHER 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. CHECK ONE ONLY: OWNER ❑ AGENT 0 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 knowledg, and that all plumbing work and installations performed under the permit issued for this application will be in compliance with 'vent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 0 2 6E ` 11-' LICENSE# 16(,f u . SIGNA MP JP❑ 16 6fo CORPORATION❑# �� / PARTNERSHIP❑.# LLC❑# COMPANY NAME 4 i/Z. /62d f /6--‘-'"74.- ADDRESS f r /47< S% CITY / rrt--J 4-4 STATE "014 ZIP Q L ? o TEL FAX CELL S, 'J(2 Jri )7 EMAIL 5;1'6 { ( /'c-i iQ/t�5: nofi�� 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