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HomeMy WebLinkAboutBLDP-21-003755 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/6/21 PERMIT# BLDP-21-003755 7 4 JOBSITE ADDRESS 11 OLD SALT LN OWNER'S NAME GUISE C NICHOLAS TRS P OWNER ADDRESS GUISE CATHY C TRS 93 JENKINS RD ANDOVER,MA 01810 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESD 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 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 WATER HEATER WATER PIPING 1 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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. PLUMBERS NAME Gregory Selfe LICENSE 26714 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME GREGORY A SELFE ADDRESS 41 SPRINGER LN CITY WEST YARMOUTH STATE MA ZIP 026734930 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK bP-21 -boi, k CITY/TOWN 0A MA DATE a- PERMIT # L 11/47471 JOBSITE ADDRESS II 0 i SA-�T L A (1e OWNER'S NAME F / o OWNER ADDRESS I ( of 1) SA-c -T .LA ne T Sog)SSY- 1 ba, FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 1-1 EDUCATIONALRESIDENTIAL 0'� PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:. PLANS SUBMITTED: YES ❑ NO FIXTURES Z FLOOR-0 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 I DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK I LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION ECEIV �....... WATER HEATER ALL TYPES WATER PIPING r � OTHER 1A.� 05 2U2.i III BUII.DIry��"" 1 1 I By: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESIA 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. CHECK ONE ONLY: OWNER 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 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 6gC6 oKrsei LICENSE # Q6.71Y SI ATURE MP ❑ JP CORPORATION ❑ # PARTNERSHIP ❑ # LLC (l # COMPANY NAME 6O1!y 5R.IG-P(cMst cetvrct- ADDRESS q1 CITY IA). reino, 1 STATE ►�1 ZIP �d �3TEL FAX CELLf°')mf" /((3 c( EMAIL SC Ire ores e- Low. r.�