HomeMy WebLinkAboutBLDP-21-005569 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/26/21 PERMIT# BLDP-21-005569
JOBSITE ADDRESS 11 NORTH COVE LANDING OWNER'S NAME RODGERS JOSEPHINE W(LIFE
P OWNER ADDRESS RODGERS KENNETH W(LIFE EST)136 MARINER LN BAY SHORE,NY 117(15T) TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL al
PRINT
CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES El NO❑
FIXTURES FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 2 1
ROOF DRAIN
SHOWER STALL 1 1
SERVICE/MOP SINK
TOILET 2 1
URINAL
WASHING MACHINE CONNECTION 1
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. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 Joseph Lemieux LICENSE 10791 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME JOSEPH S LEMIEUX ADDRESS 18 DINAHS WAY
CITY WAREHAM STATE MA ZIP 025711463 TEL
FAX CELL EMAIL js.lemsons@yahoo.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
j,= CITY rf/teiY MA DATE 1,,/22/ PERMIT#
JO SITE ADDRESS /1 `�%O'✓04 � e%-7U 1!) OWNER'S NAME G2L%j
ei
POWNER ADDRESS ✓ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Z] '
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-I BSM 1 2 3 4 5 5 7 8 9 10 11 12 13 14
BATHTUB / .
CROSS CONNECTION DEVICE / _ .
DEDICATED SPECIAL WASTE SYSTEM _ .
DEDICATED GASIOIUSAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR l AREA DRAIN _ ,
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
LAVATORY 2 /
ROOF DRAIN _
SHOWER STALL /
SERVICE/MOP SINK
TOILET
URINAL .
WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES 1
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 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 0
OWNER'S INSURANCE WAIVER:1 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 ON •'• LY: S WN ' 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
ly
I hereby certify that all of the details and information I have submitted or entered regarding this application a' - • •,. o the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i• • ,'=11.-. "II Pertinent pro • •. •f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ii
PLUMBER'S NAME
LICENSE# /D 7�/ / SIGNAT
MP lJP 0 i CORPORATION12'<i0215-.
. PARTNERSHIP 0# LLC 0#
COMPANY NAME J 5 :Lem i ee." f 5,oud Cel., ADDRESS POl?v)" ‘7- '/t/G
CITYI -f21 ,at STATE/I ZIP �� t7b/ TEL 3 ? " V/ _17
FAX
CELL b/t"Its . G5& EMAIL J- I e/11Sd)I.S e y ?) <c":tpL