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Home My WebLink AboutBLDP-23-004941 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 f. CITY YARMOUTH MA DATE 3/8/23 PERMIT# BLDP-23-004941 4 t-� % JOBSITE ADDRESS 39 UNCLE ROBERTS RD OWNERS NAME ZALDASTANI ELIZABETH(EST OF) P OWNER ADDRESS PO BOX 271 HAMILTON 01936-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El FIXTURES FLOORS-4 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 2 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION 1 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 El 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 William Woods LICENSE#1887 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME [NILLIAM T WOODS ADDRESS PO BOX 702 CITY W BARNSTABLE STATE MA ZIP 026680702 TEL FAX CELL —1 EMAIL adads10@comcast.net ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT N PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _?r CITY c C W(r MA DATE �! ,23 ✓ �� (JOS��/V f' // /� PEF�MIT — Jog' RESS S7 /14C/f e m 6k0e NEiNA E afe- / iER C �V� DRESS TEL FAX 1 TYPE OR OCCUPA YTYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL lg 'RINI`'i, DEPARTMENT -C-L kRL'f NEW.-:1 rENOVATION: E--- REPLACEMENT:❑ PLANS SUBMITTED: YES lieNO❑ FIXTURES 7. 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 i FOOD DISPOSER FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ' LAVATORY a ' ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET l , URINAL WASHING MACHINE CONNECTION / 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 VNO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY NSURANCE POUCY [ OTHER TYPE OF INDEMNITY ❑ BOND El 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT �I 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 Pertinen pro ' ion of the Massachusetts State Plumbing Code and C apter 142 of the General Laws. ' G�� PLUMBER'S NAME 6( `r l�/D67 "S LICENSE#�1� ` Vl/4�� . SIGNATURE MP❑/ JP❑ CORPORATION ❑# PARTNERSHIP❑.# LLC[�#/ COMPANY NAME_ 4'0 S P/LL44.6. 192 ADDRESS 47 `& /62-- c1TY kJ , 6 rile N r/�/ STATE of ZIP 6 �(o� ? TEL 3 �— ��jc3 FAX5'' 3 ��u CELL5bF 367 3 5 EMAIL /l d kif iO l- 7 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT it PLAN REVIEW NOTES