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HomeMy WebLinkAboutBLDP-22-004670 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • y, __& CITY YARMOUTH MA DATE 2/23/22 PERMIT# BLDP-22-004670 I" '; JOBSITE ADDRESS 15 GARDINER LN OWNERS NAME Jane Diamond P OWNER ADDRESS NH 03811 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 111 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ FIXTURES • FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 19 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 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 1 _ WATER PIPING 1 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❑ 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 Charles Cashin LICENSE 130677 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP 0# LLC El# COMPANY NAME CHARLES A CASHIN ADDRESS 14 ROBERTS RD CITY BOXFORD STATE MA ZIP 019211822 TEL FAX CELL EMAIL none ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ 0 FEES S PERMIT# PLAN REVIEW NOTES • r • Y'o r oa • e'SACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK CITY ti-r-eteswe MA DATE 7 'L 3-W1 PERMIT* 1-1-- 4410 9 SI A[)DRESS 16- Ctite- -i* OWNER'S NAME J +6- a @Nt> BOIL DEPAN 4 ADDRESS ii1} i9tt — gi2 4 TEL girl- -7506- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:Et REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURES 1 FLOOR-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/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER / • DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN T INTERCEPTOR(INTERIOR) KITCHEN SINK I LAVATORY ROOF DRAIN y SHOWER STALL SERVICE/MOP SINK i TOILET j URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / ` WATER PIPING I 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 THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND 0 • 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT L:t 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 p a ce with nent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C �( � PLUMBER'S NAME LICENSE#to L ( 7 SIGNATURE` MP 11? --,JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC 0# COMPANY NAME çILSL P IL)011,0 l ADDRESS /4 /© CITY 16,0/C-0 0f4e@ STATE AG ( ZIP O f 61'7_ I TEL l () • R©"2- FAX CELL EMAIL 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