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HomeMy WebLinkAboutBLDP-22-000118 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a. = 6 CITY IYARMOUTH MA DATE I7/8/21 I PERMIT# BLDP-22-000118 1=E= JOBSITE ADDRESS 1109 SEAVIEW AVE UNIT 7 I OWNER'S NAME!Faye Coleman P OWNER ADDRESS IMA 02715 I ITEL I I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ PRINT RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES El NO❑ FIXTURES _ 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 1 WATER HEATER WATER PIPING OTHER 2 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 Chris Poire LICENS:38901 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# COMPANY NAME LLC El# ADDRESS 37 Calvin Drive CITY Dennis STATE 121111111111111 ZIP 02638 TEL FAX E=11== CELL 7748366461 EMAIL mcplumber@gmail.com • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �' G!'►vt .,,. MA DATE 7 g- 2 i PERMIT# JOBSITE ADDRESS / U 7 5 eCv ,€P �' �OWNER'S NAME -� � ern OWNER ADDRESS TEL I /a y "3��` 91 'VAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑'� PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR—+ esM 1 2 3 4 BATHTUB 5 6 7 8 9 10 11 12 13 14 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 . j 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 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOWE( ❑ LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S URANCE WAIVER:I am aware that the licensee does not have the insurance coverage require Massac G eral Laws,and that my signature on this permit application waives this requirement. d by Chapter 142 of the t CHECK ONE ONLY: OWNER I hereby certify that all of the details and information I have submitted or entered regarding this a li El AGENT Er SIGNAT OF OWNER OR AGENT and that all plumbing work and installations performed under the permit issued for this application will be in Massachusetts State Plumbing Code and Chapter 142 of the General Laws. pp cation are true a d accurate to the best of my knowledge pli ce with all P 'Went provision of the PLUMBER'S NAME LICENSE# PL 3 3,'it' MP❑ Jp SIGNATURE CORPORATION ❑# PARTNERSHIP❑.# COMPANY NAME �;t e N C-i:J LLC❑## b aTi,t. - ADDRESS 3 7 CITY ,‘: �v.� FAX STATE ZIP i CELL EMAIL !/ TEL J