Loading...
HomeMy WebLinkAboutP-17-5900cb�r- 1 �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY IYARMOUTH MA DATE 5/12/17 PERMIT# BLDP-17-005900 JOBSITE ADDRESS 51 WINTER ST OWNER'S NAME 1SWANSON DAVID B P OWNER ADDRESS 1SWANSON SHEREE L 51 WINTER ST YARMOUTH PORT, MA 02675 EL TYPE OR OCCUPANCYTYPE COMMERCIAL RESIDENTIAL m PRINT CLEARLY NEW. ❑ RENOVATION: D REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO m 1FLOORS-___ 9 if) 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 1 LAVATORY 1 ROOF DRAIN SHOWER STALL 1 SERVICE / MOP SINK 1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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. YESEM 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. PLUMBER'S NAME ILeonard Thonus LICENS x'5520 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# E= LLC ❑#� COMPANY NAME ILeonard P Thonus ADDRESS 35 Cottonwood Rd CITY lHanvich STATE IMA ZIP 1026451809 TEL FAX I CELLI EMAIL Yes No THIS APPLICATION SERVE AS THE El ❑ os:ourr FEES$ PERMITS I I PLAN REVIEW NOTES i i 3 C MASSA HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CIN DATE J �� PERMIT # SMA JOBSITEADDRESS YJ _ �G . OWNER'S NAME r OWNER ADDRESS aVntZ,- TEL rO�_- h'1_I •,2��AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT 2"'CLEARLY NEW: ❑ RENOVATION: 2 REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO [Ly FIXTURES Z FLOOR—, BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN - SHOWER STALL SERVICE I MOP SINK I TOILET URINAL 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 22., NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THETYPE 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 apQlication waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ IGNATURE OF OWNER OR AGENT at all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge ing work and Installations performed under the permit Issued for this application will be in mpli��th all erti ant provision of the rherebyeertfy tate Plumbing Code end Chapter 142 of the General Laws. ME 4�Aala P, 770AVJS 54 LICENSE # ZO. SIGNATURE MP �JP❑ CORPORATION # PARTNERSHIP D# LLC ❑ # /❑ ��--��ff— ,,// COMPANY NAMEL_L OAZAAj l' ej(9�t, CNffADDRESS t9, 2 9 f�f� CITY.!/.1/� STA/ ZIP d TEL ! FAX CELL fdaZ3Z EMAIL C ROUGiI PLUMBING INSPECTION NOTES I 1IELOW FOR OFFICE USE ONLY I FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERM # PLAN REVIEW NOTES