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HomeMy WebLinkAboutBLDP-23-002739 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY YARMOUTH MA DATE 11/16122 PERMIT# BLDP-23-002739 JOBSITE ADDRESS 5 DUNDEE DR OWNER'S NAME CHAUSSE DAVID W • P OWNER ADDRESS CHAUSSE DENISE M 5 DUNDEE LN YARMOUTH PORT,MA 02675-1518 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 9 PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ 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 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION 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 El 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 Michael Mcbride LICENSE 19681 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME MICHAEL R MCBRIDE ADDRESS 9 Rustic Drive CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride©gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES; PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK — CITY MA DATE ((j 0 /Z.O12 PERMIT# • y r— iv JOBSITE ADDRESS _n 5- /��Un� �Q 4CY OWNER'S NAME IQ, LCw'(e y�q4 OWNER ADDRESS ( :l)1:) TEL — ?a ? AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL tg PRINT �n CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:g T 1-11"05 PLANS SUBMITTED: YES❑ NO te FIXTURES 7. 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/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 LAVATORY / • >� E I VE ®� ROOF DRAIN SHOWER STALL -NOV• qp� SERVICE I MOP SINK ICU Lug L TOILET URINAL / gILQING D=PAR7MENT 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 Q 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 I Massachusetts General Laws,and that my signature on this permit ap?lication waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT L',Y 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. / n PLUMBER'S NAME 1 `(�rs 4�l p T LICENSE#f/9(og/ . pep 1[ SIGNATURE MP❑ JP Q _ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME ('A r t ADDRESS 37 Fr41,/44 4*e CITY 1407 41) /A[ S STATE 0444 J ZIP a Z60 f TEL ?7 y 7/a 7/zZ FAX CELL EMAIL (t°CJ7>k I�G ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El FEE: $ PERMIT# PLAN REVIEW NOTES