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HomeMy WebLinkAboutBLDP-21-007331 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -6 CITY YARMOUTHkr MA DATE 6/16121 PERMIT# BLDP-21-007331 I'- 4 JOBSITE ADDRESS 5 CEDAR ST OWNERS NAME adam tate r_ P OWNER ADDRESS BURLINGTON,MA 01803 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) , KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 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❑ 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 Leon Hall LICENSE 8f/82 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME LEON R HALL ADDRESS 77 Hazel Ln CITY Brewster STATE MA ZIP 026311729 TEL FAX CELL EMAIL none ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT FEES$ PERMIT# PLAN REVIEW NOTES • MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK •"VV._� CITY YMMVG t/S MA DATE G//01'/ PERmiT#GLOP- zl-oo 33 i JOBSITE ADDRESS 3" C i Ai' C7 3: V OWNER'S NAME • erg p OWNER ADDRESS TEL /-9/7-,0/157,19VAx i TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL iiir PRINT CLEARLY NEW 0 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO,®' FDQURES 1 FLOOR-4 BSAI 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM +--' DEDICATED GASIOIUSAND SYSTEM ' DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM + - - __.a DEDICATED WATER RECYCLE SYSTEM DISHWASHER t MIMING FOUNTAIN —" .—~ , FOOD DISPOSER - •- FLOOR!AREA DRAIN _ - INTERCEPTOR(INTERIOR) , . ' I _ KITCHEN SINK - LAVATORY — • ROOF DRAW h , t SHOWER STALL I SERVICE/MOP SINK ' _ f d TOILET 1 fi __. URINAL WASHING MACHINE CONNECTION f _ EI I `�� s ;1_WATER HEATER ALL TYPES WATER PIPING OTHER `y. T I INSURANCE COVERAGE: I have a current.liabt1'Ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY ❑ OTHER TYPE OF INDBaM1Y 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does nM have the insurance coverage required by Chapter 142 of the { -. _. . - d that my signature on this permit application waives this requirement. AAAa�•� CHECK ONE ONLY: OWNER Er AGENT 0 4- NI SIGH TURE OF OWNER OR AGENT L:I hereby certify that all of the and I bare s a reg&ding IN*appal:Mon are true and mounds to the best and that all*robing work and Inatafiadons performed under the perm Issued for this application toll be In of th �s1on e Masaachusega State Plumbing Code and Chapter 142 of tine General Lam. PLUMBER'S NAME gear?iP gel/44, uCENSE 11/01 . SIGNATURE • MP% JP❑ CORPORATION❑it PARTNERSHIP Ll# LICE]. COMPANY NAMEE,,pp �y, ADDRESS 77,4 Z -4'9'�F CITY /d" J`Pr STATE/.'A ZIP OR 69/ TE1. �48'_4 �3p FAX CELL %ZX- --64 EMAIL