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HomeMy WebLinkAboutBLDP-19-001230 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .CITY [YARMOUTH MA DATE 8/28/18 PERMIT# BLDP-19-001230 !I JOBSITE ADDRESS 53 COLLINGWOOD DR OWNER'S NAME TIETGE ROGER P P OWNER ADDRESS TIETGE CHARYN A 53 COLLINGWOOD DRIVE YARMOUTH PORT, TEL MA 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:m PLANS SUBMITTED: YES❑ NO m FIXTURES 1 FLOORS-. SSM 1 2 3 4 5 I 6 7 8 9 10 11 12 13 14 BATHTUB I CROSS CONNECTION DEVICE 1 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 ROOF DRAIN SHOWER STALL _ -- SERVICE SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER I, 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m 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 Donald Mercier LICENSE 31082 SIGNATURE MP 0 JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Donald R Mercier ADDRESS 4 WILDWOOD WAY CITY SANDWICH STATE MA ZIP 025632686 TEL FAX CELL EMAIL F . ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE 0 0 c{ D DUIT FEES$ PERMIT# PLAN REVIEW NOTES o 4,9" /= 4444—/°1 • ,1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK rpt'--1. -7���, 7I CITY Yannouthport MA DATE 8/24/2018 PERM TM Bar -DD/2'AI s1RECEIVED JOBSITE ADDRESS 53 Collingwood Drive OWNER'S NAME Roger Tietgt P OWNER ADDRESS Same TEL 508-362-3441 Airdx24 2018 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENT!\L Vs PRINT BUILDING DEPARTMENT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Z PLANS S)EVd1LIIEDi.YF; �A1L FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01USAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ' DISHWASHER DRINKING FOUNTAIN F000 DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK 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 j NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z OTHER TYPE OF INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:lam 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 ❑ AGENT D SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are a and accurate to the•:i of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be Inc lance wi P -i�- ',revision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws ALJ PLUMBER'S NAME Donald R Mercier LICENSE it 31082 SIGNATi• MC JPZ CORPORATION[# PARTNERSHIP# LLCIf# COMPANY NAME Bamstable County Plumbing 8 Heating ADDRESS 4 Wildwood Way CITY Sandwich STATE MA ZIP 02563 TEL 508-420-5919 FAX CELL 508-420-5919 EMAIL bcph08@gmail.com