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HomeMy WebLinkAboutBLDP-22-007485 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 6/29/22 PERMIT# BLDP-22-007485 ' JOBSITE ADDRESS 6 FRANCES HELEN RD OWNER'S NAME REGALBUTI ARMAND TR PERS REP P OWNER ADDRESS CIO GEORGE THOMAS&ALICE TRS 17 THATCHER SHORE RD YARMOUTH TEL PORT,MA 02675 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ FIXTURES FLOORS-0 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❑ 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 Richard Olsen LICENSE 1A335 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RICHARD P OLSEN ADDRESS PO BOX 2026 CITY DENNIS STATE IMA ZIP 1026385026 TEL FAX I CELL I EMAIL loffice@olsenplumbing.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Rio ' ., _�a CITY m C MA DATE PERMIT# ZZ— 7`1 J JOBSITE ADDRESS U f yo Yl C-e h1—i-en ra cd OWNER'S NAME POWNER ADDRESS I IiTEL 1 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL �'- -- PRINT EDUCATIONAL RESIDENTIAL CLEARLY NEW:0 RENOVATION:D REPLACEMENT: EIVir PLANS SUBMITTED: YES D NOD FIXTURES 1 FLOOR-. BSM 1 2 3 4 BATHTUB _ 5 6 7 8 9 10 11 12 13 14 CROSS CONNECTION DEVICE I d - E DEDICATED SPECIAL WASTE SYSTEM ° 1 'f ,I 11 -: DEDICATED GAS/OIUSAND SYSTEM f I, j � :i 'I_ 1 DEDICATED GREASE SYSTEM f I ' s DEDICATED GRAY WATER SYSTEM 1 DEDICATED WATER RECYCLE SYSTEM , 1� i ,I 1 DISHWASHER �; I� 1 DRINKING FOUNTAIN FOOD DISPOSER �d R� illiffillialli 7111111111 FLOOR/AREA DRAIN . INTERCEPTOR(INTERIOR) ill Intant- ' l` illinIWI _- KITCHEN SINK 1f 11 I£ '1 ' • l if IS .- ' LAVATORY _ 1 I F___ 111W1110 ROOF DRAIN pa L�I' ! . °`` SHOWER STALL ant. _ [ `_ I 1� I I _ °� SERVICE/MOP SINK �(-- j _ TOILET � �� URINAL I � WASHING MACHINE CONNECTION � g� 1 I � �' ��_ S „ _• WATER HEATER ALL TYPES ' f WATER PIPING Ir�- � OTHER 1 _ _ ; , mitarimmtriumwarminumitamtwoult INSURANCE COVERAGE: 11— I I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES P1 NO ri IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. p the SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Pi AGENT ED I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac .: . �,- and that all plumbing work and installations performed under the permit issued for this application will be in co Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • • s f my knowledge �✓ c /��visi e PLUMBER'S NAME Richard Olsen ;LICENSE# M10335 '/ i MP Jp'� v'r ATURE CORPORATION S# 2166 PARTNERSHIP# ILLC # ` COMPANY NAME Olsen Plumbing&Heatin I ,. ADDRESS. P.O.Box 2026.357 Hokum Rock Road CITY Dennis STATE MA I ZIP 02638 1 TEL 508.385-5290 FAX 3 508-385 6963 =CELL ,. .�.��- EMAIL OFFICE Q