HomeMy WebLinkAboutBLDP-22-004204 #B MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 1/27122 PERMIT# BLDP-22-004204
JOBSITE ADDRESS 49 WILFIN RD 7 OWNER'S NAME GREGORY G NELSON
P OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL U
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
FIXTURFS • FLOORS-. 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 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 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 D 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 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 GREGORY NELSON LICENSE 12462 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME GREGORY G NELSON ADDRESS 48 LUNAR AVE
CITY BRAINTREE STATE MA ZIP 02184 TEL
FAX CELL 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
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
j 1 a* CITY � 1Id a4,11 n (4O �-^' MA DATE 1 `' Z�— PERMIT#
JOBSITE ADDRESS 9 I l3 t l �-t✓i OWNER'S NAME 6'
OWNER ADDRESS '/? 1.k-)Kq 2 /4 a TEL ./7 (/a1— 76/67 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL e}--
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 B 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 I • '
• DRINKING FOUNTAIN '
FOOD DISPOSER
FLOOR/AREA DRAIN �� I
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY , 1 •
ROOF DRAIN
SHOWER STALL - - ' •
'
SERVICE/MOP SINK � 1 TOILET -4/4g1
URINAL ' `5d2 I
WASHING MACHINE CONNECTION �-
WATER HEATER ALL TYPES K I r ENr
WATER PIPING f
OTHER
I 1
i - I
INSURANCE COVERAGE: 11
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
LIABILIT"INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
j Massa setts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT ❑
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 co fiance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter142 of the General Laws.
PLUMBER'S NAME�j� y /Vets an LICENSE# /2 i' 2 SIGNATURE
MP JP❑/' CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Ga 'zy AI?Iff n ADDRESS Vi �`)b11a RUC
CITY_13_e_tuf 7,re C 4 / STATE Ref ZIP Z)2/, ( TEL /i
FAX CELL�! 1 Y?9—Z,/o EMAIL(�f t'/f&.!tLJ4' C �,01,- (6 /14
•
./ U �
• 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
•