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HomeMy WebLinkAboutBLDP-21-005686 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 411/21 PERMIT# BLDP-21-005686 ,_`_ JOBSITE ADDRESS 77 ROUTE 6A OWNER'S NAME HUNT JOHN R OWNER ADDRESS SRIHADI TRI KRISNAMURTI 77 ROUTE 6A YARMOUTH PORT,MA 02675 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 2 ROOF DRAIN SHOWER STALL 1 2 SERVICE/MOP SINK TOILET 1 2 URINAL WASHING MACHINE CONNECTION 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❑ 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 Richard Bartels LICENSE#1845 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RICHARD D BARTELS ADDRESS 7 PLEASANT PARK CIR CITY HARWICH STATE MA ZIP 026452017 TEL FAX CELL EMAIL bartelspha@comcast.net 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 l CITY1TOWN yikl/Klyc[7/Y MA DATE 3—3� PERMIT# 1L�� JOBSITE ADDRESS 77 /17: G,1- y.f OWNER'S NAME `7°,64m/ 4161-4/7— OWNER ADDRESS(444l,8 G TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT ®� CLEARLY I NEW:❑ RENOVATION:[ 3 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 5:?"--- FIXTURES 7 FLOOR—, BSM 1 2 3 4 5 8 T 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01L/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY / p-. ROOF DRAIN SHOWER STALL / < SERVICE/MOP SINK TOILET I oZ URINAL WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES WATER PIPING / OTHER INSURANCE COVERAGE: 1 have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.442 YES I1 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 lancelancejft all Pe n rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws_ y% PLUMBER'S NAME /Z! 4'44D Q, ,IIWZriAr LICENSE# !!$44— SIGNATURE MP®/' JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME 844 77SGt— f ADDRESS 7 fiL P.e+z€,k CITY ht GLl Gl STATE/KS ZIP 402.6"'VS- TEL S277,A. 'O /25 FAX CELL%S7J7.23 7e2 7.3-7 EMAIL eziez7E'GtS' "i 4 cam cd4S`1'7'WV"