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HomeMy WebLinkAboutBLDP-23-000241 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK •( , E7 CITY IYARMOUTH I MA DATE I7/14/22 I PERMIT# BLDP-23-000241 JOBSITE ADDRESS 112A&12B ROSEMARY LN I OWNER'S NAME'JOHNSON NANCY L TR p OWNER ADDRESS IN L JOHNSON INVESTMENT TRUST PO BOX 342 HYANNIS,MA 02601 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 PRINT RESIDENTIAL al CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 BATHTUB10 11 12 13 14 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND 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 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 0 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 LICENS: f?093 SIGNATURE MP ❑ JP © CORPORATION ❑# jJ PARTNERSHIP ❑# LLC ❑# COMPANY NAME WILLIAM J APPLEBY ADDRESS 5 STEPHEN HOPKINS RD CITY HARWICH STATE MA ZIP 026451251 TEL FAX CELL EMAIL wjappleby@hotmail.com -4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l , . � .._—CfY�E ,sr?"- ad"',77001'4) MA DATE 6/1-4-7.2.Z PERMiT# 2.3 - v 2-Li/ • 1 4 ,2 ITE CRESS /Z43 ke5SCfrryd,r y _L 7� OWNER'S NAME y .jrrs_ DRESS 0,Raid 3 / n-/,'! int i ( ofJ s 2Fd-/o r 2PAx DG DEFA /° AI BUIL V02/U O OAGOi TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES 1 FLOOR-, BM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE • DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ' INTERCEPTOR{INTERIOR) KITCHEN SINK I' LAVATORY F ROOF DRAIN SHOWER STALL f SERVICE I MOP SINK TOILET / URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING c 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 Lam' OTHER TYPE OF INDEMMTY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware_aware that the licensee does not have the affiance coverage required by Chapter 142 of the Massachusetts General and that my signature on this permit application waives this requirement. ��� CHECK ONE ONLY: OWNERAGENT 0 SI RE OF OR A I hereby certify that all of the details and information I have submitted or erred regarding this application are true and ac cisate to the best of my knowledge and that all plumbing work and installations per fwuRt under the permit issued for this application will be in compliance with aN Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Lava. . PLUMBER'S NAME�I//I c/-n J /,4 J7�LICENSE# 3 a 0!91`; � IGtVA; 21 i'� MP❑ JP$ CORPORATION❑# PARTNERSHIP 0# LLc❑n# COMPANY NAME �TPium 1))'hi -1— ,,__ / /h ADDRESSeZN3O A�)0 L Cd rci— CITY W J/1 Af// /7I J� o STATE/WA- LP 02(-4,(O-7 TEL FAX C4 Er 0 - 31/ EMAIL LJJ cp IUDy@- ADfi'h�/ /,, COO')