HomeMy WebLinkAboutBLDP-22-005804 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
u to CITY YARMOUTH I MA DATE 4/11/22 , PERMIT# BLDP-22-005804
.hta JOBSITE ADDRESS 111 WHARF LN OWNER'S NAME WARD RICHARD R
P OWNER ADDRESS WARD SUSAN E 511 PINE TREE DR NE ATLANTA,GA 30305 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑
PRINT
CLEARLY NEW:El RENOVATIONS.El REPLACEMENT El PLANS SUBMITTED: YES NO El
FIXTURFS FI°ORS—. RSM 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 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
WATER PIPING
OTHER 1
OTHER DESCRIPTION:ejector
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El BOND El
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 wit be in compliance with at Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Kenneth Duarte LICENSE MA SIGNATURE
MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Kenneth j Duarte ADDRESS 37 collins ave
CITY Centerville STATE MA ZIP 02632 TEL
FAX CELL 5082502763 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ El
FEES$ PERMIT#
PLAN REVIEW NOTES