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Home My WebLink AboutBldp-22-000755 i r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y- €� CITY YARMOUTH MA DATE 8/9/21 PERMIT# BLDP-22-000755 I' � JOBSITE ADDRESS 16 RIVER ST OWNER'S NAME Ben Dziczek P OWNER ADDRESS NJ 07830-3520 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO El FIXTURFS • FLOORS-0 BSM 1 2 3 4 5 , 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 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❑ 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 John Cloonan LICENSE f2038 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP 0# LLC El# COMPANY NAME JOHN CLOONAN ADDRESS 19 PRINCE PATH CITY SANDWICH STATE MA ZIP 025632407 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 S PERMIT# PLAN REVIEW NOTES v • ben D a; c Z21L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK W "'- CITY j "\ MA DATE O -" Zr J PERMIT# LLI ' o ,tL JOBSITE ADDRESS C7 v j OWNER'S NAME \ 0 �� C �C �..� I OWNER ADDRESS �1 --�--C TEL'1 7 I `2 z-1` (c"FAX W`' TY �( OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO e---. FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB J CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM — DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER ---, DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ] a ROOF DRAIN SHOWER STALL I SERVICE/MOP SINK TOILET f 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 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ BOND 0 ' OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT L'sl 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 compf ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME LICENSE#(zD3 53 SIGNATURE MP Er.JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC❑# COMPANY NAME C_103,NJ/1-9' Q I V`" • ADDRESS 11 f li CITY S 4\—J( 4"-A (�t.� STATE GY►A ZIP V 4-j 3 �--�� TEL FAX CELL`�C�S •q 30 OW EMAIL C l cyyt•Jk--‘A---r-.669-evNeis,_..S*,,,e- . ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT#_ PLAN REVIEW NOTES