HomeMy WebLinkAboutBLDP-22-002812 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 11/16/21 PERMIT# BLDP-22-002812
1=� JOBSITE ADDRESS 4 GULLS COVE RD OWNERS NAME LOWENTHAL DANIEL A
P OWNER ADDRESS LOWENTHAL NAOMI M ONE SOUNDVIEW DR LARCHMONT,NY 10538 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 1
LAVATORY 2
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
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 El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El 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 (Adam Hufnagel I LICENSfi16256 I SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I 1 LLC ❑# I
COMPANY NAME ADAM HUFNAGEL PLUMBING& ADDRESS 1167 Carriage LN
HFATING I I r
CITY (Barnstable I STATE IMA I ZIP 102630
I TEL I
FAX I I CELL 15083177409 I EMAIL Ithehuff483@comcast.net
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`e-' )_ _ ___ �I CITY_ �t1'i°'���1 MA DATE Z PERMIT# Z L- Zvi Z
JOBSITE ADDRESS b y L U vf
OWNER'S NAME // z-ow'e/1 ���
P OWNER ADDRESS z�N\ '�. TELCh t,l - r;1161 �t�®k
FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:0 RENOVATION:L REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7
BATHTUB e 9 10 11 12 13 14
CROSS CONNECTION DEVICE ( MO
DEDICATED SPECIAL WASTE SYSTEM all
DEDICATED GAS/OIL/SAND SYSTEM -
DEDICATED GREASE SYSTEM EN
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN -
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR) nil
✓) i LAVATORY _
cy I ROOF DRAIN _
V I SHOWER STALL I MN
...? I SERVICE/MOP SINK
11 TOILET ,
j URINAL I _��
- WASHING MACHINE CONNECTION " ��„ wg.,
C� jWATER HEATER ALL TYPES111111.111111111111
WATER PIPING �M1MI.
OTHER I
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INSURANCE COVERAGE: -
--1-1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKINGL1 0 ❑THE APPROPRIATE BOX BELOW
E POLICY ��
( Massa OTHER TYPE OF INDEMNITY 0 BOND 0
®
J
LIABILITY INSURANCE
OWNER'Susett INSU GenerRANCE WAIVELa I have i chs al ws,andR: thatam myaware signaturethatthe on
licensee this permitdoesnot onthe wa ves this requ remenquired by Chapter 142 of the
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑
L.I I hereby certify that all of the details and information I have submitted or entered regarding this application are lie and accu
that all plumbing work and installations performed under the permit issued for this application will be in co liance wi - :II P- ' ent provision o
Massachusetts State Plumbing Code and Chapter 142 of the General Laws, e to ' best of my knowledge
f the
PLUMBER'S NAME ABC -\�V\Cc f i LICENSE# 15 Z 5(o - L
MP ❑Jp SIGNATURE
CORPORATION 0# PARTNERSHIP❑.# LLC, (
COMPANY NAME C�l(/''k A./sf-YV3v! ' P ' I�tt D ��
,✓1 5 t ,n ADDRESS �G 7 r fit �Z c
CITY �� �lf STATE t"t 7 ,
FAX ------_ ZIP _l� S�� TEL
EMAIL
CELL S 31 7` 7 K 0 1