HomeMy WebLinkAboutBLDP-21-005656 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY YARMOUTH MA DATE 3/31/21 PERMIT# BLDP-21-005656
I' ' - JOBSITE ADDRESS 11 CARVER RD OWNERS NAME WAITE THERESA M TR
P OWNER ADDRESS CARVER ROAD REALTY TRUST 9 BROUSHANE CIR SHREWSBURY,MA TEL
01545-2050
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES El NO m
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/OIUSAND 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 1
ROOF DRAIN
SHOWER STALL 1 1
SERVICE/MOP SINK
TOILET 1 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 III NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND❑
OWNERS 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 R Peter Checkoway LICENSE 113417 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME checkoway enterprises ADDRESS 11 scargo hill rd
CITY DENNIS,MA 02638 STATE MA ZIP 02638 TEL
FAX CELL EMAIL
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