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HomeMy WebLinkAboutBLDP-23-003262 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Is— MA DATE I12112122 I PERMIT# BLDP-23-003262 CITY YARMOUTH ki JOBSITE ADDRESS 15 MINNETUXET WAY OWNER'S NAME IRYAN THOMAS G JR I P. OWNER ADDRESS RYAN KRISTIN L P 0 BOX 148 YARMOUTH PORT,MA 02675 TEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO FIXTURES 1 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET _URINAL WASHING MACHINE CONNECTION _WATER HEATER WATER PIPING 1 OTHER 1 OTHER DESCRIPTION: ice maker INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY 0 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. SIGNATURE PLUMBER'S NAME (Gregory Selfe ILICENS426714 MP ❑ JP © I CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I ( COMPANY NAME IGREGORY A SELFE I ADDRESS I41 SPRINGER LN 41 SPRINGER LN CITY WEST YARMOUTH I STATE IMA I ZIP 1026734930 I TEL I IWEST FAX I I CELL I I EMAIL Iselfegreg@y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ CITY YAR Mo,t+, MA DATE ion-/a-a.a, PERMIT# 2_ i-�= JOBSITE ADDRESS i 5.- m(n A e.f L/X d f2.GtJa4y OWNER'S NAME Y Any P OWNER ADDRESS 15 tin I 4 n t TV k cf 1(41-y T LS0Sl4' 'C76a FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALgl. PRINT PLANS SUBMITTED: YES ID NO 0 CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:❑ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 6' 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM DISHWASHER L • DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK i LAVATORY . ROOF DRAIN SHOWER STALL • - SERVICE I MOP SINK I TOILET URINAL WASHING MACHINE CONNECTION \ - WATER HEATER ALL TYPES WATER PIPING L OTHER 1-cc viikk t Ntrt&pa INSURANCE COVERAGE: I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Cep NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY i 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT L'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 66'°/ey ce- LICENSE#a6'r 4 . 0 IG TURE MP 0 JP® CORPORATION❑# PARTNERSHIP❑.# LLC❑# b O 4 lit sPiernd F.� Gpnt CITY COMPANY NAME �� �A PL"�'6 Rik�A'v``c' ADDRESS 73 TE So 2) >7$-lY 3Y �/, /4KM0 4 STATE M ZIP FAX CEL(Sog)nQ- /y;Y EMAIL Seiec gift e. )04100.(49",