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HomeMy WebLinkAboutBLDP-23-005831 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , ( CITY IYARMOUTH MA DATE 4/20/23 PERMIT# BLDP-23-005831 OWNER'S NAME ROCK DIANE B TR JOBSITE ADDRESS 27 PAR 3 DR P OWNER ADDRESS D B ROCK REV LVG TRUST 27 PAR 3 DR SOUTH YARMOUTH,MA 02664-2129 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES El NO❑ FIXTURES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 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 (Gregory Selfe I LICENSEI26714 I SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME IGREGORY A SELFE I ADDRESS 141 SPRINGER LN 41 SPRINGER LN I CITY (WEST YARMOUTH I STATE IMA I ZIP 1026734930 I TEL I FAX I I CELL I I EMAIL Iselfe re I g g@yahoo.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - =_�'1- CITY YA C M o,` --) l i=^y MA DATE �'�`a 3 PERMIT# 2.- S!"37 JOBSITE ADDRESS PI4 4 3 De t ye OWNER'S NAME Gg 1 -c 6 P OWNER ADDRESS .31 PAR 3 De wC 4.2)v)9 9'-1 9 Q f FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IZ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:{ . PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR--4 BSM 1 2 3 4 5 6 7 B' 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 SYSTEM DISHWASHER _ , . " - DRINKING FOUNTAIN " FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY T-7-7 DRAIN SHOWER STALL • SERVICE/MOP SINK TOILET URINAL , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ,Trri 4ton R eg lev / _ 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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY 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 i Massachusetts General Laws,and that my signature on this permit aptalication waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I 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 6pervo seia LICENSE#c)6 7 i c f . "--a U SIG ATURE MP El JP® CORPORATION 0# PARTNERSHIP❑.# LLC❑# COMPANY NAME C9re(o S c- a e((-l1?6U 05 S 1"C ADDRESS l( Sere rosere- -Ault CITY ("}- YkK'/1v` STATE Mil ZIP od6'13 TE(s°$) 7-1_/`t3 ti FAX CE001-2 b'/V 3 y EMAIL S UCe 8(e$ e ` 49• C o)-A., 1 4.1 rn 0 z z 0 U W z a 4 z w 20 z ) O F- vn . cn ccW 0 4a °- 4* z _ 1' O a w > CO IL g 0 w - O zo c.( a p cat al a 1 a a. cn = W F- 11 rn H 0 z O k Li- 0. p - t. z v, z c v LMI