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HomeMy WebLinkAboutBLDP-23-001843 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 10/6/22 PERMIT# BLDP-23-001843 I' JOBSITE ADDRESS 15 JEFFERSON AVE OWNERS NAME OLSON JOHNATHAN E p OWNER ADDRESS LARRIMORE KIMBERLY 15 JEFFERSON AVE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m 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/OIUSAND 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 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 John Kane LICENSE 22755 SIGNATURE MP 0 JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME JOHN KANE ADDRESS 39 MONOMOY RD CITY S YARMOUTH STATE MA ZIP 026641984 TEL • FAX CELL EMAIL jkanee45@yahoo.com Ia0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK --art :ski yore nl C MA DATE l o f 4-1 X. PERMIT# z— [f L13 05 211fSf AC DRESS f l Y TeFf"rrcci /9 u t' OWNERS NAME 'ok, d 150 n [�Ut� NG DhFAS IW�I DRESS S '`►'►r TEL FAX By OK U�.AurHNGY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL al. PRINT CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO(if FIXTURES 1 FLOOR-4 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 SYSTEM DISHWASHER I ---� DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 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 RI NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE OF INDEMNITY ❑ 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 ❑ AGENT ❑ 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 wi hiall Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. lit"-, PLUMBERS NAME LICENSE# ill SIGNATURE MP❑ JP g CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME X4 nC Ka - ref C IYIg ADDRESS 3 9 Manama,/ 2 ci ' CITY S- kf4V+M STATE VLCk ZIP a '? ci TEL FAX CELL 50$' -G S -5-4 Sb EMAIL