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HomeMy WebLinkAboutBLDP-23-000238 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK p: CITY !YARMOUTH MA DATE 7/14/22 PERMIT# BLDP-23-000238 JOBSITE ADDRESS I12A&12B ROSEMARY LN OWNER'S NAME JOHNSON NANCY L TR D OWNER ADDRESS IN L JOHNSON INVESTMENT TRUST PO BOX 342 HYANNIS,MA 02601 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:0 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 1 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 (William Appleby I LICENS432093 I SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP 0# LLC ❑# I COMPANY NAME IWILLIAM J APPLEBY I ADDRESS 15 STEPHEN HOPKINS RD CITY IHARWICH I STATE IMA I ZIP 1026451251 I TEL FAX 1 1 CELL 1 1 EMAIL (wjappleby@hotmail.com 0O' --� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY- 7a.rhioc1 /j MA DATE C J':i 1 PERMIT# • L 1 41 A DRESS �oZA��sSGyr1 ryes L &fr7 OWNER'S NAME J'V�-►'1C'y .�O h/j i, TRESS /°b. 2o/.341 /J ann,d� /�7Tkl TE �OFf .7�d_/oy?FAX BUI ING DE n � By USG b % TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL►� PRINT CLEARLY NEW:❑ RENOVATION,' REPLACEMENT:❑ PLANS SUBMITTED: YESX NO❑ FIXTURES 7 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ _ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _ KITCHEN SINK II LAVATORY J ROOF DRAIN SHOWER STALL / ' SERVICE/MOP SINK TOILET / URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES Ali 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 gr 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. t' CHECK ONE ONLY: OWNER AGENT ❑ 6 OF OWNER R GE I hereby certify that all o 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 Perti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME id>/I/4L+r7 7-ism CS ,14 LENSE# 3-2 O? ' ATURE 4,41". MP❑ JP' CORPORATION❑# PARTNERSHIP❑# LLC❑# / COMPANY NAME �f�.F PJ4 -1' b6h ')-/14C.a..1L-;y� ADDRESS 2d o Pi•n ci ecao c (i r-Ca`e. CITY �r�//7 /e STATE MN- ZIP O•L(o 6 7 TEL FAX CEL(r6)4/0*/'3//(i EMAIL a)J a pplr b( e h Ai-1y)a, �. CO,