HomeMy WebLinkAboutBLDP-22-000678 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ei CITY YARMOUTH MA DATE 8/6/21 PERMIT# BLDP-22-000678
fir' °2 JOBSITE ADDRESS 22 CAPT STANLEY RD OWNER'S NAME POTTER MICHAEL L
P OWNER ADDRESS POTTER KATHRYN L 8901 W KAY LN TOLLESON,AZ 85353 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO m
FIXTURFS • 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 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
OTHER 1
OTHER DESCRIPTION:sewage ejector pump
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 El 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 Donovan LICENSE 15443 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP 0# LLC ❑#
COMPANY NAME Capewide Plumbing and Heating ADDRESS 135 Captain Small Rd
CITY South Yarmouth STATE MA ZIP 02664 TEL
FAX CELL 7749941894 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ El
nprawser
FEES$ PERMIT#
PLAN REVIEW NOTES