Loading...
HomeMy WebLinkAboutBLDP-19-002990 RMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 11/15/18 PERMIT# BLDP-19-002990 JOBSITE ADDRESS 12 FLINTLOCK WAYOWNER'S NAME LYONS JENNIFER L P OWNER ADDRESS WILSON JULIE ANN 2 DETMER AVE TARRYTOWN, NY 10519 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL Q PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NO❑ FIXTURES .1 FLOORS— RSM 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK • _LAVATORY _ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 Richard Olsen LICENSE Si'166 I SIGNATURE MP 0 JP 0 CORPORATION Q# 2166 PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS PO Box 2026 CITY Dennis 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 ❑ ❑ DtDUIT FEES$ PERMIT# _PLAN REVIEW NOTES • Nv . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' 1st) CITY YARMOUTH MA DATE November 15,'; PERMIT# BLDP-19-002990 JOBSITE ADDRESS 12 FLINTLOCK WAY OWNER'S NAME LYONS JENNIFER L G OWNER ADDRESS WILSON JULIE ANN 2 DETMER AVE TARRYTOWN NY 10519 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ • NOD FIXTURES FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER • BOOSTER • CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR . FURNACE GENERATOR GRILLE • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER - WATER HEATER 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. YES 0 NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITYD 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-GASFITTER NAME Richard Olsen LICENSE# 2166 SIGNATURE MPO MGFD JPO JGFD LPGI❑ CORPORATION p# 2166 PARTNERSHIP ❑# LLC❑# COMPANY NAME: ADDRESS PO Box 2026, CITY Dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL 11 S31ON M3IA3d Wild #111/113d $:33J ❑ 01I1Al2i3d 3Hl SV S3Ael3S NOIlVOIIddV SIHl ON SaA 9310N NOILO3dSNI 'MNld AlNO 3Sf1 2i0103dSNI 210d 30Vd SIH. S31ON NOIIO3dSNI SV0 HOfOb T ,