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HomeMy WebLinkAboutBLDP-23-004624 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/21/23 PERMIT# BLDP 23 004624 al I I JOBSITE ADDRESS 11 SPARROW WAY OWNER'S NAME KING JAMES J P OWNER ADDRESS KING LORETTA R 11 SPARROW WAY SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 2 LAVATORY 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 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 0 NO 0 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 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. 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 32655 SIGNATURE MP ❑ 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 • MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK t-T. j CITY St.y.,, j- Li t,rwl Ui.t%t MA DATE 2-ZI-Z3 PERMIT# 23 — tiG 2.41 JOBSITE ADDRESS 1 1 S?Arrov LAI Col OWNER'S NAME / ,4-0 r7rl r"g OWNER ADDRESS I I SI2GrrvL,J IJCn9 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:e REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND 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 Z • ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET Z ___ URINAL WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES 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 b No ❑ IF YOU CHECKED YES,PLEASE INDICATE TH 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 II Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ 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 / LICENSE#3-�S SIGNATURE MP❑ JP(1d CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME CC'J i iV940,763>� ADDRESS Z C6i,(,Lir.i7 6614,1, JR(;) CITY 5 G 411 4rn7c STATE ' A ZIP 02-CC&[ TEL FAX CELL S13 -L(. c L1'1 G.Z EMAIL 1-6 f4 gefO^ iov S c:,1Cc1�,�