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HomeMy WebLinkAboutBLDP-21-004453 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK p CITY YARMOUTH MA DATE 2/5/21 PERMIT# BLDP-21-004453 ` JOBSITE ADDRESS 17 EDDY ST OWNER'S NAME MARK AND DARLENE HANDY P OWNER ADDRESS 2801 SW 38TH ST CAPE CORAL,FL 33914 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES _i 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 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❑ 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 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 Lorne Jussila LICENSE 31971 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# I Lc ❑# I COMPANY NAME LORNE B JUSSILA ADDRESS IPO BOX 131 CITY WEST HARWICH STATE IMA I ZIP 1026710131 I TEL I FAX I I CELL I I EMAIL Ilornejussila@hotmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1.e�'�''�� �, CITY � l�__.% �,(`(Nj 0 L,' �� � PERMIT# 1�JU'`V� : tiqs5 . _ Ert -� L'V,), 1� MA DATE C6c, �� JOBSITE ADDRESS TI (C Q sic �Cd OWNER'S NAMES/Gj� Gl I'f' Di • � OWNER ADDRESSCO 1 �L� `S j� TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NOO FIXTURES 1 FLOOR-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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ _ DRINKING FOUNTAIN _ FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) _ KITCHEN SINK LAVATORY ( ROOF DRAIN (,� SHOWER STALL _ ------125 SERVICE/MOP SINK .` ..s „:. I " ►:... ffJ TOILET j URINAL r WASHING MACHINE CONNECTION' WATER HEATER ALL TYPES WATER PIPING - 1 • uil__• ING ,ErJA I ME ,!T OTHER ''y - - - 1 _ . . .- r A • • 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YEiiid NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. CHECK ONE ONLY: OWNER 0 AGENT L SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru and accurate • a t of my knowledge • and that all plumbing work and installations performed under the permit issued for this application will be in co iance ' h a •-' in provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # 519qi SIGNATURE , MP ❑ J CORPORATIO # PARTNE HIP 0 # / Lc 0# COMPANY NAME ' i�lr ) : -laity ADDRESS kOsikE V pod CITY ‘ t)N.1 r ) r STATE MA"Yg ZIP6 -7 TEL FAX CELL(). 'J 7 7& OP EMAIL,�U roto Lr 11 c 7iNai 1 . (-GM US � Li