HomeMy WebLinkAboutBLDP-21-000171 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH JOBSITE ADDRESS 1589 WEST YARMOUTH RD MA DATE 17/13120 PERMIT# BLDP-21-000171
OWNER'S NAME TIMOTHY CHAPASKO
P OWNER ADDRESS 119 BROWNING AVENUE SOUTH YARMOUTH 02664 I TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1 3
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 1 3
URINAL
WASHING MACHINE CONNECTION 1 2
WATER HEATER 1
WATER PIPING 1
OTHER 1
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
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.
PLUMBER'S NAME John Downey LICENSE 3/2070 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 76 Swift Brook Rd
CITY (south yarmouth STATE MA ZIP 02664 TEL I
FAX CELL 5082215257 EMAIL
RO JGH PLUMBING 'SPE TION I TES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
��/ ��/j/,.�/G Yes No
��dd THIS APPLICATION SERVE AS THE PERMIT
FEES$ PERMIT#
PLAN REVIEW NOTES