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HomeMy WebLinkAboutBLDP-23-004619 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/21/23 PERMIT# BLDP-23-004619 M JOBSITE ADDRESS 21 SULLIVAN RD OWNER'S NAME ronaldo desouza P OWNER ADDRESS 21 SULLIVAN RD WEST YARMCUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 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) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK _TOILET 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER WATER PIPING OTHER 1 OTHER DESCRIPTION: bar sink 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 D 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 Anson Celin LICENSE 32655 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# [ PARTNERSHIP ❑# LLC ❑# COMPANY NAME ANSON CELIN ADDRESS 26 Capt. Blount Rd CITY South Yarmouth STATE MA ] ZIP 02664 TEL FAX CELL —I EMAIL ansoncelin@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES • MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK -4-- CITY 4,0 vs+ c`f-tr\ MA DATE 2- 1- Z.3 PERMIT# JOBSITE ADDRESS e 1 Svi riv,;,,l G.30 OWNER'S NAME G.1r,J1. (,'. J�5�._rz OWNER ADDRESS .Z! c„ I,v-41•7 a (U TEL COS--S)C<)-Sad U FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL©- PRINT CLEARLY NEW: ❑ RENOVATION:e REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE!MOP SINK TOILET URINAL , WASHING MACHINE CONNECTION j WATER HEATER ALL TYPES WATER PIPING OTHER 12,4,,.r INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ea NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY 471. 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. - CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT -.I 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 co pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE#3ZG'SS SIGNATURE MP❑ JP d CORPORATION ❑# PARTNERSHIP❑.# LLC❑# Lr� COMPANY NAME ei;:1 � �tti�il�,7,5 ADDRESS 2[- � �<,'`:14.,� CITY 56,e I L/e7r//I fr'4'r/' STATE:/1 7 f l ZIP Cl 'LC G t f TEL S C+b - o- (-/7‘,L__ FAX CELL EMAIL 41Ui'lL r-I%r15✓U`141114x7r(cn —_ 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