HomeMy WebLinkAboutBLDP-21-002914 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ilAr74 = CITY YARMOUTH MA DATE 11/20/20 PERMIT# BLDP-21-002914
JOBSITE ADDRESS 858 WEST YARMOUTH RD OWNERS NAME NEIER DENNIS S
'mac v'
P OWNER ADDRESS IKRUPKIN MARISHA E 150 EAST 77TH ST NEW YORK,NY 10075 TEL
TYPE OR OCCUPANDY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
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 2
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1 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❑ NO ❑
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❑
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 requiement.
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 end 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 (William Woods
I LICENSE1#1887 SIGNATURE
MP El JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑#
COMPANY NAME 'WILLIAM T WOODS I ADDRESS IPO BOX 702
CITY W BARNSTABLE I STATE IMA ZIP 1026680702 TEL I I
I I
FAX
CELL I -1 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEESS PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-�'- ,11- . MA DA E t / PERMIT
__)_ a CITY
JOBSITE ADDRESS OWNERS NAME 41.
P OWNER ADDRESS TEL TEL ----
FAX -----
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ILI
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
FIXTURES 1 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 _ _ _ _
INTERCEPTOR(INTERIOR) _ ,
KITCHEN SINK
LAVATORY /
ROOF DRAIN . _ _
SHOWER STALL I
SERVICE/MOP SINK
TOILET / / _
URINAL
WASHING MACHINE CONNECTION ,
WATER HEATER ALL TYPES
WATER PIPING _
OTHER _
INSURANCE COVERAGE:
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES !O ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I OTHER TYPE OF INDEMNITY ❑ BOND E
OWNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i; Massachusetts General Laws,and that my signature on this permit application waives this requirement.
.. CHECK ONE ONLY: OWNER ❑ AGENT ❑
t—
SIGNATURE OF OWNER OR AGENT
`.:1 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 provisio f f the
Massachusetts State Plumbing Code and Chapt r 142 of the General Laws. I /,/ K ' GT
PLUMBER' NAME 0/ if 1 ' 0 S LICENSE#//eg ? SIGNATURE
MP JP❑ CORPORATION E} PARTNERSHIP❑.# LLC❑#
COMPANY NAME n _ /) /7cs /7/Cflf/di/iy ADDRESS l U 4dk ?c f
CITY III,' g,4/ f STATE j ZIP 6 266 TEL L 0 "7 .3J
FAX )' -l- CELL. 6 3 ! -3e EMAIL /7-0/7 ,) J'/o /P /c COtit/
\V
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