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HomeMy WebLinkAboutBLDP-23-001683 3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 9/28/22 PERMIT# BLDP-23-001683 JOBSITE ADDRESS 9 GILBERT ST OWNER'S NAME Mark Handy • n OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES 1 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 1 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 1 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❑ 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. PLUMBERS NAME Ilome jussila LICENSE 3/1971 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 184 Bog Lane CITY WEST HARWICH STATE IMA ZIP 102645 TEL I FAX 1 CELL 15087768943 EMAIL Ilomejussila@hotmail.com • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK — Ari_ - CITY So IJ fill U I v` MA DATE a (3,oac� PERMIT# 2-3 - I (` 2 3 JOBSITE ADDRESS ? C 61 be <11 OWNER'S NAM OE/Ig_f _b- 6,114 P OWNER ADDRESS /7 f deb Si TEL5' SD9-DszFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATIONt REPLACEMENT:❑ PLANS SUBMITTED: YES 0 N0 FIXTURES 1 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/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 f LAVATORY l f F Z: �/ I ROOF DRAIN r'-- SHOWER STALL I • _ S¢T P 2 8 202-2 - SERVICE I MOP SINK _ TOILET L.-- I URINAL LiuiLui vc., ut-INKrMENT i . WASHING MACHINE CONNECTION J _ 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. Y4 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCI OTHER TYPE OF INDEMNITY 0 BOND ❑ 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 1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura o the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co an c li Pe ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# 3I 9 7( . SIGNATURE MP 0 JP)] CORPORATION 0# PARTNERSHIP❑.# LLC gi# COMPANY AmW /T //0 ADDRESS 874 /aie lk- c A STATE MI ZIP C �/Si— TEL J�S.-77�-F7r-7 CITY �lnll � 2C�1 / FAX CELL EMAIL d<h�CI:r�� d� �.�CI . G0 4,31 I/o 'CZ)