HomeMy WebLinkAboutBLDP-22-004412 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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s CITY YARMOUTH MA DATE 2/8/22 PERMIT# BLDP-22-004412
JOBSITE ADDRESS 76 GREAT WESTERN RD OWNERS NAME VAN SISE JANET L
P OWNER ADDRESS 76 GREAT WESTERN RD SOUTH YARMOUTH,MA 02664-1311 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES El NO❑
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 , 12 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
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
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
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❑ 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 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 Matthew Hyland LICENSE 313776 SIGNATURE
MP ❑ JP D CORPORATION ❑# PARTNERSHIP ❑# LLC ❑
COMPANY NAME MATTHEW HYLAND ADDRESS 127 COPELAND ST
CITY BROCKTON STATE MA ZIP 023016958 TEL
FAX CELL EMAIL hylandhvac@gmail.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑
FEES E PERMIT#
PLAN REVIEW NOTES
I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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la 2 xi Ots7a,A) ' OWNER'S NAME. ft�k, - k ,lS
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OWNER ADDRESS _ .. L Oe-,157:: qj !FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: 3 PLANS SUBMITTED: YES 0 NO
FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB R l_
CROSS CONNECTION DEVICE ._.. .- __ ....--ii.rialr lai,--... 4 hi.-.-- .10..."'-...s
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM ,. , ,
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DEDICATED GREASE SYSTEM '
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DEDICATED GRAY WATER SYSTEM i �,
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DEDICATED WATER RECYCLE SYSTEM I �i J
DISHWASHER ,
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DRINKING FOUNTAIN -----,
FOOD DISPOSER _
FLOOR I AREA DRAIN s _. .._ s _.-_
INTERCEPTOR (INTERIOR) 1
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W_
KITCHEN SINK y
LAVATORY ---__f.. _4,,... r---- um
ROOF DRAIN ,111101
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SHOWER STALL
SERVICE I MOP SINK - j►
TOILET r - f iit...„,
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URINAL r -- - ! - .�
WASHING MACHINE CONNECTION - __ a-7—, f ' =
WATER HEATER ALL TYPES -- . 1 I `
WATER PIPING �--
OTHER CACLue __ __,ILL.AA . -- ' - - -7:----- 1 ,i1 -:--- --.' ,_ -__=.1=iirmm: ,__ _. _j ..,1
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INSURANCE COVERAGE:
l 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 i xl 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER D AGENT I
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 an acc a ' to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in oompli e it Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME AAVV,VJ M LAnI b 1 LICENSE # 7.7Cc SIGNATURE
MP JPL4 CORPORATION #i IPARTNERSHIPD#E. _ . __ ILLCD#1 I
COMPANY NAMEItiL3 J _AVM ADDRESS I3?, r.Q�.
CITY! Rtmo o LA.. .. ._ ___ _m_--_.._ STATE ZIP 0a3 TEL 7 �- 0 (- .7(%
FAX CELL s : EMAIL 11 ((,/1,-,) .6 JdVtAC GAMtc. .Cl�rv�-