HomeMy WebLinkAboutBLDP-22-003225 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 12/7/21 PERMIT# BLDP-22-003225
JOBSITE ADDRESS 11 WEDGEMERE RD OWNERS NAME ALBRECHT KELLY M
P OWNER ADDRESS 11 WEDGEMERE RD WEST YARMOUTH,MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT'.El PLANS SUBMITTED: YES NO❑
FIXTIIRFS FLOORS— RSM_ 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
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❑ 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 Adam Larsen LICENSE 3/3750 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADAM LARSEN ADDRESS 8 FARNHAM ST
CITY IBOSTON I STATE IMA ZIP 1021192908 I TEL
FAX I CELL I I EMAIL I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVE AS THE 0 0
FEES$ PERMIT#
PLAN REVIEW NOTES
_ RECEIVED
DEC 06 2021 _
JI -- r ES DFI TS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
4 BJILDI --- NT g5 W3�2`�
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,_ _ cITY n�G�-t-� MA DATE 1 z -.(o - Z o z 1 PERMIT#
vvr I� OWNERS NAME K. l I j f\\ r-ec k--
JOBSITE ADDRESS I e � q P Y�e e Rol
1
P OWNER ADDRESS I I Val e ci1 C 1 ✓1�-e(2 RBI TEL(003 q 03 1`i FAX
TYPE OR OCCUPANCY TYPE COMMERCIALI 0 EDUCATIONAL 0 RESIDENTIAI,,
PRINT
CLEARLY NEW:0 RENOVATION:, REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
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 X
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE 1 MOP SINK
TOILET .
URINAL .
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
VV ak-e-r ei\1--eC
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 Os OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WANER: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 ❑ 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 compliance with all Pertinent provision of�
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — -- _ 12�Cis
PLUMBER'S NAME j\dgm L Ar SeYl LICENSE# 33 5O 4`I ATURE
MP 0 JP 1 CORPORATION 0#nn Ob'10yInU\I `U Mi � PARTNERSHIP 0# LLCC El#
COMPANY NAME IV` b NeaDDREaa��SS LI`1 0 1 a VW h(n(t Ind,
CITY
I"c 0(-E V1 C \a-VV1(A VIA STATE M A ZIP O Z 19 5 0 TEL
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FAX CELL 1�`11
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