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Home My WebLink AboutBLDP-22-001673 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK It_- CITY YARMOUTH MA DATE 9/23/21 PERMIT# BLDP-22-001673 JOBSITE ADDRESS 16 WEIR RD OWNER'S NAME DEXTER JEFFERSON S TRS P OWNER ADDRESS DEXTER DINA G TRS 16 WEIR RD YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY 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 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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 D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND D 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 LICENSE 311056 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME THEO PLUMBING AND HEATING ADDRESS P.O. Box 397 P.O. Box 397 IIC CITY Centerville STATE 'MA ZIP 02632 TEL FAX CELL EMAIL theoplumbing@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ar'i CITY f -, 0� art ZI 2GZ �_=-1=1= MA DATE 1 PERMIT# JOBSITE ADDRESS I in ln1e-I/ 114 ti Cl/ —{ OWNER'S NAME IC'(( 'Sc--e6-, pPx 1-P--- POWNER ADDRESS C We,7 ko..i TEL S°'5 c'65 6 dN4t FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT �, / CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:L/ PLANS SUBMITTED: YES❑ NO El 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!AREA DRAIN R f ,_ INTERCEPTOR(INTERIOR) _ KITCHEN SINK SF 1 " ! LAVATORY ROOF DRAIN SHOWER STALL B SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I 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"NO ❑ IF YOU CHECKED YES, PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY El BOND El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 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 U 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 th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 0•0^0 k G S Tro ,G t- ' •e)3LICENSE# 3 k4 -.56 7SIGNATURE MP❑ JP[ CORPORATION PARTNERSHIPo ❑# ❑.# LLC(�# 0 13 c1/4443 Z COMPANY NAME -ckeb e( 1r.) a---,d Ifeo,4, A RESS 0.d Nov c.$) CITY Ceti le/✓•i 1 C STATE 1' `kx ZIP Q Z 6 `c2 TEL SOg 7 6 3 6 1 FAX CELL EMAIL Ik ea 0`-'v•-.6' ( "-pr sOo. C c - sv - .-- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT [ I FEE: $ PERMIT # PLAN REVIEW NOTES