HomeMy WebLinkAboutBLDP-23-003472 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 'YARMOUTH I MA DATE I12123122 I PERMIT# BLDP-23-003472
JOBSITE ADDRESS 1100 WEBBERS PATH I OWNER'S NAME IHAAG LISA ANN
P OWNER ADDRESS 1144 CHAPPAQUIDDICK RD EDGARTOWN,MA 02539 I TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO El
FIXTURES FLOORS RSM 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 I 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: YES NO 0
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 Ikeilh farnham LICENS4#1601 SIGNATURE
I PARTNERSHIP El# I I LLC ❑#I
MP 0 JP El CORPORATION ❑#
I57 whites path
COMPANY NAME ;south shore heating cooling ADDRESS
CITY 'south yarmouth I STATE IMA I ZIP 1026640000 I TEL 15083986901
FAX I I CELL I I EMAIL I
/ .
Fes.
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE
FEES$ PERMIT#
PLAN REVIEW NOTES