HomeMy WebLinkAboutBLDP-23-001142 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.
,,F-,, CITY YARMOUTH MA DATE 8/31/22 PERMIT# BLDP-23-001142
I I -a� JOBSITE ADDRESS 15 WINSLOW GRAY RD OWNERS NAME Jennifer Calle
P OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO El
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 El NO El
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 El
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 Anson Celin LICENSE 3R655 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ANSON CELIN ADDRESS 26 Capt.Blount Rd
CITY South Yarmouth STATE MA ZIP 02664 TEL
FAX CELL EMAIL ansoncelin@yahoo.com
F
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r0 " 1 ci.rri- UtAr'r✓' ""._,. MA DATE PERMIT# 2,3- //'/2-
AU 31 202Bs TE 'DDRESS 1,S rUJ tnb 10vv /CTrul/ OWNER'S NAME LI t0�c( CG. ((
B J I LD I DE PAI? OWNER •DDRESS ( � (AI r/vs (6W (St-u(,TMENT � 2 TEL '7 74,446-16 / FAX
BY ""' - . CY TYPE COMMERCIAL EDUCATIONAL- ❑ ❑ RESIDENTIAL Xer-
PRINT �/
CLEARLY NEW:ElLL�
RENOVATION: J REPLACEMENT:❑ PLANS SUBMITTED: YES El 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/OIL/SAND SYSTEM I '
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM :
DEDICATED WATER RECYCLE SYSTEM '
DISHWASHER .
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I
KITCHEN SINK I -
LAVATORY
ROOF DRAIN I r
'
SHOWER STALL / '
SERVICE I MOP SINK '
TOILET f '
URINAL , -
. WASHING MACHINE CONNECTION '
WATER HEATER ALL TYPES I
WATER PIPING '
OTHER '
I -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES VINO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V OTHER TYPE OF INDEMNITY 0 BOND 0
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.
�� CHECK ONE ONLY: OWNER ID AGENT El
SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accuiate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co pIiance with all ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME CIS o✓1 CZ (;{ LICENSE#3 5S-- SIGNATURE
MP❑ JP CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Cte 110 % [E/141bj09 ADDRESS Cc I( A1,1 i3I_6U1r),i- V<s.)
CITY A l'\ ��rn�d�til`\ STATE"') Tt- ZIP 42.6.6-41 TEL 50i-' LI6-Y 6;1- -
FAX CELL EMAIL A A.5611(f(in V if HOO- (G r)1