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HomeMy WebLinkAboutBLDP-23-005985 P' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK zo CITY YARMOUTH MA DATE 4/28/23 PERMIT# BLDP 23 005985 t" ; JOBSITE ADDRESS 25 CAPT SMALL RD OWNER'S NAME GABRICK STEPHEN J JR P OWNER ADDRESS CIO TEEHAN MARK J 6 CAPTAIN EDGAR DR NORTHBOROUGH,MA 01532 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES z FLOORS—+ BSM 1 2 , 3 , 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 _ CROSS CONNECTION DEVICE 1 1 _ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND 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 2 ROOF DRAIN SHOWER STALL 2 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER _ WATER PIPING 1 OTHER 1 t OTHER DESCRIPTION:outdoor shower INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY❑ BOND 0 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 matthew coleman LICENSEI3k1368 SIGNATURE MP 0 JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME MATT COLEMAN PLUMBING AND ADDRESS 5 college st I-IFATINA - CITY west yarmouth STATE MA ZIP 026733792 TEL FAX CELL 9788854343 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El ❑ FEES S PERMIT# PLAN REVIEW NOTES r.1) ' — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ':_iiiii_L----4 CITY C ci1 l r-MOtt i1 MA DATE `"t 7 g / 5 PERMIT# I — S 59t JOBSITE ADDRESS ar c a Ty] cti'i t II r0 OWNER'S NAME fJar^k TC`Ck 7 I2tah a' POWNER ADDRESS 4 ea r)-ri 1-1/1 c,1/1/1 7 l I 1 c( TEL'7g-s 'Y13 FAX rg TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[i PRINT CLEARLY NEW:0 RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES EV NO 0 FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8' 9 10 11 12 13 14 BATHTUB 1 - - _ CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER i . DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ KITCHEN SINK LAVATORY —1' R EC— Cr Ikilt" ROOF DRAIN -- I SHOWER STALL a —. SERVICE I MOP SINK A� 2J 2023 TOILET A . URINAL r c �U uE N.T. 1 - . I WASHING MACHINE CONNECTION By ----_ WATER HEATER ALL TYPES _ WATER PIPING OTHER Fli5tnIf s -h' ti I ` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES gr NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY d OTHER TYPE OF INDEMNITY ❑ BOND 0 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. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I 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 P ' nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � , PLUMBER'S NAME N 1- h'eiN cc., e,imairt LICENSE#-N 76 SIGNATURE MP❑ JP LEI CORPORATION 0# PARTNERSHIP Q# LLC 0# COMPANY NAME I TI (44), itl7 PA' fr ADDRESS 5 c I( yt' si CITY fAJe /" Kit lii 44 1'ln STATE Zat ZIP Uo�^/�n TEL TEL�"i n7 6 - ?.7-1 'c1Zj FAX CELL 017 0--gg' ✓ q3L/ EMAIL 1".R'Ct9k U,U,vt LIMO";r1C.''') l 'lilGi.11 , 600/ . CC9i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES