Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Bldp-19-006394
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 5/13/19 PERMIT# BLDP-19-006394 I JOBSITE ADDRESS 16 FOREST GATE VILLAGE OWNER'S NAME GLINSKI BRIAN A P OWNER ADDRESS GLINSKI NANCY M 16 FOREST GATE YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO ID FIXTURFS z 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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 III NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER TYPE OF INDEMNITY 0 BOND El 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 2/166 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# 2166 PARTNERSHIP El# LLC ❑# COMPANY NAME THE HOKUM ROCK ADDRESS PO BOX 2026 Ct7RPfRATIC)N INC 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 ❑ El FEES$ PERMIT# ',�J�� / 5/�eA A PLAN REVIEW NOTES G� ��