HomeMy WebLinkAboutBLDP-22-001816 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 9/29/21 PERMIT# BLDP-22-001816
JOBSITE ADDRESS 722 WILLOW ST OWNER'S NAME SWENSON ALAN M
P OWNER ADDRESS SWENSON LINDA M 10 MORNING GLORY CIR WESTFORD,MA 01886 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0
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CLEARLY NEW:D RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES t FLOORS RSM 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❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ 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 as 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 shane gleason LICENSE't6470 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Brewster burner service ADDRESS 229 whifftetree ave
CITY brewster STATE MA ZIP 02631 TEL 5083859702
FAX 5083854106 CELL 15082822053 EMAIL
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