HomeMy WebLinkAboutBLDP-21-002377 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,a CITY YARMOUTH MA DATE 10/29/20 PERMIT# BLDP-21-002377
I OWNER'S ADDRESS 64 EVERGREEN ST OWNER'S NAME MATTSON CARL E
P OWNER ADDRESS MATTSON MARGARET L 64 EVERGREEN ST SOUTH YARMOUTH,MA TEL
02664-5612
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Eil
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURES FLOORS-- BSM 1 2 _3 4 5 6 7 8 9 10 11_ 12 13 14
BATHTUB 1
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
SERVICE/MOP SINK
TOILET g 1 _
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 El NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El 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 Gary Jones LICENSE;.:90 SIGNATURE
MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME [3c Jones Plumbing&Heating ADDRESS 12 Yeoman Drive
CITY West Yarmouth STATE MA 7 ZIP 02673 TEL
FAX 1 ' CELL 5085092725 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY JJ FINAL INSPECTION NOTES
( // ❑Ye' ❑ di° 126 Z O
O / 3 2 THIS APPLICATION SERVE AS THE PERMIT L �S
/ /,4 FEES PERMITH
PLAN REVIEW NOTES