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HomeMy WebLinkAboutBLDP-19-004536 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =_ : CITY JGt,f✓vL.ca "` MA DATE 2- /1 /,q PERMIT#, . -157YV 'f ffe JOBSITE ADDRESS 2 Q V t rye W ad01 /�'''c // OWNER'S NAME I l^4 V` 4,l r POWNER ADDRESS 9 ✓-2 ��-a 1 N 5'/ v t U.(a TEL - ?cf 2/2 /3Z/FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:Et PLANS SUBMI I I ED: YES❑ NO❑ FIXTURES 1. FLOOR— BSIvi 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 1 AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I' I LAVATORY /I . DRAIN SHOWER STALL • ,. d_ SERVICE I MOP SINK , } '`:, > - TOILET - 1' _ _ , , ,: _ URINAL . 1 WASHING MACHINE CONNECTION / ' t = t' WATER HEATER ALL TYPES /4 WATER PIPING / OTHER - ,_ _ i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES$ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY l5Z OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the I` Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT Ili 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 w' I'Pe ' errtpro 'sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /"'fr ---- PLUMBER'S NAME LICENSE# . N URE MIAn JP❑ CORPORATION❑# PARTNERSHIP❑.# 1LLC❑# COMPANY NAME s>0 Q g -)T y P J o',g i A) !s ADDRESS /bzg KR � /^) CITY 6 itr ti 4" S ii'l - 1/S STATE ("t ZIP 4:72 P V-fi TEL 7-77 2(2 /3e9 FAX CELL EMAIL l- 4t1 1 ' L© ( &ram tL' •C • 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 r A ti Hall,'Lee From: Tom Gavin <tcgavinl0@gmail.com> Sent: Thursday, November 21, 2019 9:22 AM To: Hall, Lee Attention!'This ail on uts de of the org�tion Do not ripen attachments or click links unless you aresure this;-em s from a known sender and you know thew content'is afe. Call.the ender t nave -if.unsure Otherwise deleteOtherwtse deletethts Hi lee. This is tom Gavin with shark city plumbing. I was asked to reach out to you because of a job on 28 pinewood in yarmouth . I was released of the job and A Dad's plumbing is taking it over for meagher construction. I no longer do any business with them . Thanks any questions let me know. 774 212 1329. 1