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HomeMy WebLinkAboutBLDP-22-007364 <4,',1� dr�r.�.1 G /z3 /z 2 /�/, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 6/22/22 PERMIT# BLDP-22-007364 JOBSITE ADDRESS 248 CAMP ST UNIT H1 OWNERS NAME I_NORRIS JANICE RACINE J P OWNER ADDRESS 248 CAMP ST HI WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL al PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURFS 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY❑ BOND 0 OWNERS 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. PLUMBERS NAME Scott Andreasson LICENSE 1D794 SIGNATURE MP 0 JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# LLC ❑# COMPANY NAME ISCOTT ANDREASSON ADDRESS 37 ROBINS WAY CITY HARWICH I STATE IMA I ZIP 1026452513 I TEL FAX I CELL I I EMAIL Inane 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 - j=ry` CITY - �G(I VVtO \.1 MANDATE 2? 7 7___ PERMIT# IJOS ADDRESS -2\f C G--Y/C S 0 ( OWNER'S NAME (v ©r✓ /I jp 22 MINE AEDRESS U TEL FAX TYPE OR OCC ANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL l< :UIL )f DEP/ARTMENT 'Y CLEARty__--N W D RENOVATION:❑ REPLACEMENT;:'\ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 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 _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER , DRINKING FOUNTAIN _ _ FOOD DISPOSER _ _ FLOOR 1 AREA DRAIN _ INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY • , ROOF DRAIN _ SHOWER STALL SERVICE 1 MOP SINK — TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING OTHER - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESj, 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 t 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 t e 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. PLUMBER'S NAME 'C(..---AT , v-q_r•4)Grd-CC. -7 LICENSE#/6 � ( . � ��`— SIGNATURE MP JP❑ (� CORPORATION❑# PARTNERSHIP D#n LLC❑# COMPANY NAME J�-r-,)i I- 6I�„-n�• V e/✓i c ADDRESS S v<G4 t✓).� C�-t- CITY ,.- i,li- STATIrv7`7 ZIP C'� TEL `rL'‘—L(Ic'— 2-7 ?k` FAX CELL EMAIL 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 ti