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HomeMy WebLinkAboutBLDP-21-007514 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -E� CITY YARMOUTH MA DATE 6/24/21 PERMIT# BLDP-21-007514 3� JOBSITE ADDRESS 29 GROVE ST OWNERS NAME OLSEN ROBERT G P OWNER ADDRESS OLSEN HELEN M 7 WOODLAND PL GRANBY,CT 06035-2520 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO 0 FIXTURES 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/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 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❑ 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 0 OWNERS 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. PLUMBERS NAME Corey Sibbio LICENSE p1795 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME ICOREY SIBBIO ADDRESS 190 PLUM ST CITY W BARNSTABLE STATE MA ZIP 026681436 TEL FAX CELL EMAIL fccgunsmithing@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT E FEES S PERMIT# PLAN REVIEW NOTES �~ 28/139 - PID 1452 MASSACHUSES UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ~ West Yarmouth 6/24/21 &1��� 7.(-00-75-01 QTY MA DATE PERMIT ~ ' JOBSITE ADDRESS 29 Grove Street OWNERS NAME Robert Olsen - � 7 \0Jood|andP| ��nanbv (�TD8O35 �~ � [*VNERADDRESS ` TEL FAX �� ^ _ OCCUPANCY TYPE COMMERCIAL ���� EDUCATIONAL ^� RESIDENTIAL IE PRINT '' �- - NEW:� RENOVATION:�� REPLACEMENT:� PLANSSU0N�� YB� NO� _ -- . -- -- -- ---'-- FIXTURES --' FLOOR—, 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 _ __. DO}�ATEDWATER RECYCLE SYSTE� DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 4, LAVATORY v ROOF DRAIN SHOWER STALL "N _ — SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ' - OTHER VVSURANCE COVERAGE: � I have a currenliability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES0O NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UA8|UTYINSURANCE POLICY E OTHER TYPE OF INDEMNITY CI 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. CHECK ONE ONLY: OWNER �� AGENT �� SIGNATURE OFOV�)ERORAGENT �� ^~ I hereby certify that allhereby certify that all of the details and information I have submitted or entered regarding this applicationare true and accuratem e best of my knowledge and that all plumbing work and installations performed under the permit isfor M^»»au`v»��a�'rpmrm/noCode and cxap�,14cmm theoonol Laws. "" with of the PLUMBER'S NAME y I 10 L/&'z/C� -~� �� LICENSE# 24795 // S oNATURE MP El JP 8] CORPORATION# PARTNERSHIP 0# LLC # COMPANY NAME Corey Sibbio ADDRESS 7 Gleneagle Dr. CITY Centerville STATEMA ZIP 02648 TEL 508-685_4605 FAX CELL' EmA|L fCcgUnsnlithiDg@grnai|.ConO