HomeMy WebLinkAboutBLDP-23-000800 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
use- CITY YARMOUTH MA DATE 8/16/22 PERMIT# BLDP-23-000800
Ih.AF-13
- JOBSITE ADDRESS 21 ICE HOUSE RD OWNERS NAME SWEDLUND THOMAS E
P OWNER ADDRESS SWEDLUND CONNIE J 21 ICE HOUSE ROAD SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL ❑
PRINT
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑
FIXTURES • FLOORS—s 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 3
ROOF DRAIN
SHOWER STALL 3
SERVICE/MOP SINK 1
TOILET 3
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER 1
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 D NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY m OTHER TYPE OF INDEMNITY❑ BOND❑
OWNERS 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.
PLUMBERS NAME Christopher Keith LICENSE MA SIGNATURE
MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Keith Brothers Plumbing,Inc. ADDRESS 19 Milford Street
CITY Plymouth STATE MA ZIP 02360 TEL
FAX 1 CELL 5088632469 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Nes \u
THIS APPLICATION SERVE AS THE 0 0
FEES$ PERMIT#
PLAN REVIEW NOTES