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HomeMy WebLinkAboutBLDP-23-003733 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r w, CITY YARMOUTH MA DATE 1/10/23 PERMIT# BLDP-23-003733 ' JOBSITE ADDRESS 82 CHIPPING GREEN CIR OWNERS NAME HAMMOND WENDY M P OWNER ADDRESS CIO BROWN RAYMOND 10 ANDREWS DR UXBRIDGE,MA 01569 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO m FIXTURES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 2 URINAL WASHING MACHINE CONNECTION 1 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 m 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. PLUMBERS NAME John Downey LICENSE MA SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 37 Bray Farm Road North, CITY Yarmouth Port STATE MA ZIP 026751551 TEL 5082215257 FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El FEES$ PERMIT# PLAN REVIEW NOTES