HomeMy WebLinkAboutBLDP-22-003751 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 1/6/22 PERMIT# BLDP-22-003751
JOBSITE ADDRESS 13 DIANE AVE OWNER'S NAME JANEK ROBERT J
P OWNER ADDRESS JANEK ELIZABETH A 13 DIANE AVE SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
FIXTURES I FLOORS-4 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION 1
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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
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 Richard Olsen LICENSE 1035 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# ' LLC ❑#
COMPANY NAME RICHARD P OLSEN ADDRESS PO BOX 2026
CITY DENNIS STATE MA ZIP 026385026 TEL
FAX CELL EMAIL office@olsenplumbing.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 FOR A PERMIT TO PERFORM PLUMBING WORK
_� g _' CITY �„�>m� Z _ ,
`—"�,— .�j ( __ I MA DATE JPERMIT # t
JOBSITE ADDRESS
b 1(1!l, 004..._ i OWNER S NAME
OWNER ADDRESS
I TEL FAX! I
TYPE OR OCCUPANCY TYPE COMMERCIAL E; EDUCATIONAL RESIDENTIAL I .I
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: T' PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i --, .._ __..
CROSS CONNECTION DEVICE ___
DEDICATED SPECIAL WASTE SYSTEM 1_ — I.
DEDICATED GAS/OIL/SAND SYSTEM ____
DEDICATED GREASE SYSTEM _..,_ _'
I
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _.. _
DISHWASHER _ _
DRINKING FOUNTAIN ---�
FOOD DISPOSER ` _. .i ..... _.
FLOOR /AREA DRAIN @__ __ �` - .
INTERCEPTOR (INTERIOR) -
KITCHEN SINK _�
LAVATORY _ .... .:.::,.... .
.e
ROOF DRAIN `_
SHOWER STALL
SERVICE / MOP SINK _ . _._
TOILET _w. _
URINAL ---_ .� , _ _. _.. . _
WASHING MACHINE CONNECTION -_.. ... _
1
WATER HEATER ALL TYPES �"
,
WATER PIPING �.. __�. :._�1
OTHER _..._.... - ..--. . _
. ...__.M.. ..,...,.._._.. _ f ;
.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 F
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 i AGENT
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 accufAte th: :€s f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co . c i 14Pe flovisio he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LICENSE # M10335 � " �� �`=!
PLUMBER'S NAME J Richard Olsen ATURE
MP i JP -,,,, _ CORPORATION . # 2166 PARTNERSHIP _#1 LLC[I#
COMPANY NAME Olsen Plumbing & Heating ADDRESS ; P.O. Box 2026. 357 Hokum Rock Road
CITY Dennis -"„
STATE MA ZIP 02638 TEL 508.385-5290
FAX 508-385-6963 CELL EMAIL ovv,Ce p OIL E IJ p L V I'1'1. 6 1 . CO r"l