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HomeMy WebLinkAboutBLDP-23-004679 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/23/23 PERMIT# BLDP 23 004679 JOBSITE ADDRESS 38 EARLY RED BERRY LN OWNER'S NAME PENDLETON NANCY A P OWNER ADDRESS 38 EARLY RED BERRY LN YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 • PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES FLOORS 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) . KITCHEN SINK 1 LAVATORY 1 ROOF DRAIN SHOWER STALL 1 _ 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 0 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. PLUMBERS NAME LICENSE 10021 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS CITY STATE ZIP TEL 7816901654 FAX CELL EMAIL ine ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES • $Z MASSACHUSETTS��//�� UNIFORM APPLJCATION FOR A PERMIT TO PERFORM PLUMBING WORK I CITY yav✓4 0�`� \ MA DATE 62 j Z PERMIT# JOBSITE ADDRESS 3 ���''1(, Red P?e r''"f (Z�e OWNER'S NAME /Z i i c 1�Q P OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[-- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED: YES 0 NO❑ FIXTURES'1 FLOOR-4 SSM 1 2 3 4 5 6 7 6' 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 SYSTEM 1SE,EC IILD • = _ DISHWASHER / DRINKING FOUNTAIN 1 2031 FOOD DISPOSER FLOOR I AREA DRAIN BUILDING 4E PART INTERCEPTOR(INTERIOR) y -_ KITCHEN SINK LAVATORY / • ROOF DRAIN _ _ SHOWER STALL / SERVICE/MOP SINK _ _ TOILET /' 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"NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAVER: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 .41 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 m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P t of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# /c0 _f . SIGNATURE MP[r JP❑ CORPORATION t ZeC- PARTNERSHIP Q# LLC 0# COMPANY NAME��// /V r ��'" ADDRESS Za 0 Y�`' 45). CITY (e.)/?(5L/ 44'J- ' STATE /VM ZIP &O eG TEL 7r/-69 /�1 7 FAX CELL EMAIL 7e44ht - (g/ 9(/k Cc�'!�