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Home My WebLink AboutBLDP-22-006090 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK o*-; ! CITY YARMOUTH MA DATE 4/21/22 PERMIT# BLDP-22-006090 V / JOBSITE ADDRESS 474 STATION AVE UNIT 2 OWNER'S NAME PAINE STEVEN B P OWNER ADDRESS MANDEL GERALD&PAINE PAMELA A 474 STATION AVE UNIT C SOUTH TEL YARMOUTH,MA 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL D PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ 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) 1 KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK 1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION:water line to coffee station 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 David Michalowski LICENSE 15722 SIGNATURE MP D JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME DAVID R MICHALOWSKI ADDRESS 22 GREENLAND CIR CITY YARMOUTH PORT STATE MA ZIP 026752183 TEL FAX CELL EMAIL davemichalowski@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEESS PERMIT It PLAN REVIEW NOTES . /C'S, }) ., • •CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK {'_ CM' 4. ��r�d+X MA DATE y//G�/ PERMIT# I `R 1 4.AUTE .DDRESS G/) `7 I7:o-74,a,1 /Jve f�, fr 7 OWNER'S NAME ,`fCL/cr) A/r.c ��yW/�/1�t� +�F,ESS .� -, TEL-C 79h'5/`177 FAX EPxtFlTr BURNG D �' - ky-t UUI:UPANUY TYPE COMMERCIAL Q" EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: Ey RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO FIXTURES Z FLOOR-, 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 t DEDICATED WATER RECYCLE SYSTEM J DISHWASHER DRINKING FOUNTAIN J FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY / ROOF DRAIN k ' SHOWER STALL V SERVICE/MOP SINK TOILET URINAL tWATER WASHING MACHINE CONNECTION HEATER ALL.TYPES WATER PIPING '��7771 OTHER 7:i, ,-roof (�-,-c;,JP — 41 Zn-Ita-ce,p-i'cf L,,,..-e, / c6L fo Co�fi.C� -gyp r-i,9/cri -- -- INSURANCE COVERAGE: ' 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO t' IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW D LIABILITY INSURANCE POLICY 1-_] OTHER TYPE OF INDEMNITY ❑ BOND El OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 1 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT ❑ SIGNATURE OF OWNER OR AG T ICI 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 com liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME-ThAL' e /1ic4b le,r..",f k- LICENSE# /S 7 Z Z — SIGNATURE MP L/ JP e( CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME 41 'cZo)o-i if kJ "%r,,.,,6,,,, ADDRESS ,g02 .rre.Y1 /ror01-- C,;tie CITY ,.ol,11en--TL-po -'1 STATE""10 ZIP Qao 1 TEL FAX CELL77�f9q 1 7,5 EMAIL tie" ' !oc r j t7,,01-O'b, (dy+-) ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES