HomeMy WebLinkAboutBLDP-22-003739 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY YARMOUTH MA DATE 1/5/22 PERMIT# BLDP-22-003739
r JOBSITE ADDRESS 4 CENTERBOARD LN OWNER'S NAME PERLMAN STEVEN M
P OWNER ADDRESS PERLMAN LISA A 20 HEMLOCK RD LIVINGSTON,NJ 07039 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m
PRINT
CLEARLY NEW: 0 RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES NO m
FIXTURES z 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/OIUSAND 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 1
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
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 co NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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.
PLUMBER'S NAME Thomas Flynn LICENSE 34167 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 118 wayside dr
CITY harwich STATE MA ZIP 02645 TEL
FAX CELL 5082413438 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑
FEES S PERMIT#
PLAN REVIEW NOTES