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HomeMy WebLinkAboutBLDP-22-006386 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a CITY YARMOUTH MA DATE 515/22 PERMIT# BLDP-22-006386 ri= Clm ° JOBSITE ADDRESS 29 OUTWARD REACH OWNER'S NAME Bill Tarnowski , P OWNER ADDRESS 29 OUTWARD REACH YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO❑ FIXTURFS • 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 LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION:saniflo pump 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 0 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 Ryder LICENSE 113619 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME JOHN J RYDER ADDRESS 36 DIXON DR CITY MASHPEE STATE MA ZIP 026493191 TEL FAX CELL EMAIL arplbg@gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY t:1 MA DATE -q- 2 2- PERMIT# Z — Co $b .`1 g�� JOBSITE ADDRESS G� �/t��i� OWNER'S NAME J4.�� l!_ e 61 OWNER ADDRESS TEL FAX 7i I(iNCW-SK TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAtr PRINT CLEARLY NEW: E RENOVATION:Xr REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES T FLOOR-I 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 • 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 ALL TYPES i WATER PIPING OTHER �v vv113 INSU ANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent entt 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 CHECK ONE ONLY: OWNER ❑ AGENT El L1 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 complian w' all Pe ' ent pr ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE"• NAME LICENSE#1 l q SIGNA RE MP JP❑ CORPORATION ❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME Lt.✓A ( eLI3(4 ADDRESS x(>'A1 L it CITY �l STATE ZIP r TEL lj (� FAX � �g3 6" 4J 3 g0 CELL ` r l EMAIL ,fi