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HomeMy WebLinkAboutBLDP-23-005472 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .1 CITY YARMOUTH MA DATE 4/3123 PERMIT# BLDP-23-005472 E ' JOBSITE ADDRESS 30 JOHN HALLS CARTPATH VILL OWNER'S NAME HIGGINS ELLEN T TR P OWNER ADDRESS 30 JOHN HALL CARTWAY YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL E PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO 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/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 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 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❑ 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. I LICENS43F1971 SIGNATURE PLUMBER'S NAME home jussila ( MP ❑ JP © CORPORATION ❑# I I PARTNERSHIP ❑# I I Lc ❑# I COMPANY NAME ADDRESS 184 Bog Lane CITY WEST HARWICH STATE IMA I ZIP 102645 I TEL I ( FAX CELL I5087768943 I EMAIL Ilornejussila@hotmail.com ti • MASSACHUSETTS UNIFORM APPLJCATION FOR A PERMIT TO PERFORM PLUMBING WORK g j, 1_LIT.]0{. %001K p6 t MA DATEAr 4iRcr.9.3 PERMIT# Al re 03 2d61$SITT A DRESS �O iO UIY'- 114(/ G�/lAPVJ OWNER'S NAME h t 4G- Yq ( lJ _ UL3 '7b3 Ali 1Mpi TE I7 FAX _ OWNER DRESS •UILD G DEPERTMENT = - Y TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT PLANS SUBMITTED: YES 0 Nk�` FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8' 9 10 11 _ 12 13 14 B BATHTU CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND 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 ROOF DRAIN SHOWER STALL , SERVICE/MOP SINK _ TOILET _ 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. YESI NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ( 4 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 ❑ 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 accurate too. > t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli wi -1' 7 provision of the Massachusetts State Plumbing Code and Chapi#r 142 of the General Laws. PLUMBER'S NAME A- "�e- � �11 LICENSE# 3 l cl 4 lll SIGNATURE LUM MP❑ JP 6. i 1 , CO P RATION 0# PARTNERSHIP❑.# LLC 0# COMP NAME P/ 1217 f i( ADDRESS i!d 8 791%'L�i CITY th.6 al C k STATE//i l ZIP 6Cd 6/ < TEL FAX CELL 7C5e5:776— U`- 3 EMAIL