HomeMy WebLinkAboutBLDP-23-000675 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•' qr CITY YARMOUTH MA DATE 8/9/22 PERMIT# BLDP-23-000675
JOBSITE ADDRESS 58 WEIR RD OWNER'S NAME TAKACH MICHAEL J
P OWNER ADDRESS 56 PAYSON PATH WEST YARMOUTH,MA 02673-1523 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL m
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTIIRFS 1 FLOORS-' 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1 1
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER
WATER PIPING 1
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 Robert Cannon LICENSE 18414 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME WINCHESTER AVE ADDRESS PO Box 366
CITY Marston Mills STATE MA ZIP 1026480366 TEL
FAX CELL EMAIL Icannonsplumbingandheaing@yahoo.com
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
•
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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_�1— s' CITY (u\,1 t )-1 p c:.;(L.L MA DATE .ri'iii -9.a- PERMIT# ''.3 -- c:. c-7.1--- _
JOBSITE ADDRESS 69 tAel R_ li`e_i. ' OWNER'S NAME I; 1's?12y 21 Af
POWNER ADDRESS CD l 1 P N t'u7�17 _ \Z-- • TEL 7 2y' d 3(.0"S,25"I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL%
PRINT
CLEARLY NEW: ❑ RENOVATIONS REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR--F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r _
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
INTERCEPTOR(INTERIOR)
KITCHEN SINK T
LAVATORY I /
ROOF DRAIN
SHOWER STALL / -
SERVICE/MOP SINK
I TOILET
:I URINAL
WASHING MACHINE CONNECTION
i 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)i NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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
II Massachusetts General Laws,and that my signature on this permit application waives this requirement.
`. CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
L',-I I hereby certify that all of the details and information I have submitted or entered regarding this application e and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will i compli c rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME A,b'}Q,�\- C CA—'n.r\V c"— LICENSE# (e3 j SIGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIPNE� ❑.# LLC❑#
COMPANY NAME Cl 1--,\r1 C711 S `4 I'O1 ADDRESS / (J 3 r
f CITY' ' ci / t-°lS *Wit I J( STATEON- ZIP Z') (!q TEL C
FAX CELLI2V._ LP 3" LP 13' EMAILC YA-n 11-00 p`wAN L3Loscirb --v`o
r 'ay)co; C,n'l.
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