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HomeMy WebLinkAboutBLDP-23-005610 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -'a CITY YARMOUTH MA DATE 4/10/23 PERMIT# BLDP-23-005610 JOBSITE ADDRESS 86 EILEEN ST OWNER'S NAME DAWKINS JULIET A M P OWNER ADDRESS P.O.BOX 1391 NANTUCKET 02564-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW:El RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES NO 0 FIXTURES FLOORS— BSjv1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 1 OTHER 1 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 El BOND El 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 Eugene Volosevich LICENSE25144 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP El# LLC ❑# COMPANY NAME EUGENE VOLOSEVICH ADDRESS Pi-Forest Rd CITY West Yarmouth STATE MA ZIP 026732843 TEL FAX CELL EMAIL VOLLOGG@MSN.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 . r /91ti ,% MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Y �n ( Pe --ItfF'.0� Z 3-DU.S6J0 L = Cit (Town: fr 0 lJ , MA. Date. rt ee �- / L v �� 5iJ Owners Name: I) 4 fbtt4'w ,` Building Location: /'� Type of Occupancy: Commercial n Educational n Industrial Institutional ❑ Residential [kY New: E. Alteration: C Renovation: E Replacement: ❑ Plans Submitted: Yes n N CI 1-- r, . w Li re) FIXTURES v i o IX cy Z; Q Z ; 2 , o W o ' o ' 5 1 cn cn C) ; O j W Z CO ! J = H W d 1 ZQ CO a. ce Z 1 Y ,„ cn Q Q z D Z Z Z D �W/ i 5 , a 8 cn i o ce a w U L- a co u) 2 0 °` x 1i CO m O_j ' Q W Ca Q Q Z Et O Ce W W Z W cn Z U (3- LL. o cn w c ce ce ct Q Y = O 0 F.' = Z Q a Y Z 1 w— W w l w c� I- I a 0 cn 1- v > > 0 0 0 z I i Q m m o o u. (.9 = Y J J ` CC cn cn ; 1— D 5 41 5 5 O SUB BSMT. BASEMENT I ) 1 _ ^ 1 ,7 / / 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5 ' FLOOR _ 6T FLOOR 7TH FLOOR 8'" FLOOR j ( Check One Only Certificate # Installing Company Name: LiG/& &itJL1 ULc->5dV7 e 1 ❑ Corporation Address: 6' iTi��r f2g' City/Town: . 7' c1TState:.,vifl ❑ Partnership Business Tel: 6. t 7 - S 9.2 - 4 it f Fax: .� / ❑ Firm/Company LNa! Liceed Plumber: ��j,/6 '/if z""' MO S' L Vi G II ------- ----- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes n No If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. 1 A liability insurance policy 7 Other type of indemnity n Bond I, OWNER'S INSURANCE WAIVER: I Qaware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts general Law nd tha my signature on this permit application waives this requirement. Check One Only t% Owner \ Agent n L Signature of Own or wne Agent i I hereby certify tha 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 th 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 aid Chapter 142 of the General Laws. By ._;.Type of License: l _ Title _ 2 Plumber Signet e f Licensed Plumber 1 Master City/Town L-;fourneyman L;cense Number: w . r J APPROVED (OFFICE USE ONLY) ---____—