HomeMy WebLinkAboutBLDP-22-006526 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
y CITY YARMOUTH MA DATE 5/12/22 PERMIT# BLDP-22-006526
ra JOBSITE ADDRESS 33 PLEASANT ST OWNER'S NAME FALLOWS MARJORIE R(LIFE EST)
P OWNER ADDRESS 33 PLEASANT ST SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑v
PRINT
CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES ID NO El
FIXTURFS FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 2
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 1 3
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK 1
TOILET 1 2
URINAL
WASHING MACHINE CONNECTION 1
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 El NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ 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 Eugenijus Jagminas LICENSE 8620 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME EUGENIJUS R JAGMINAS I ADDRESS 34 ELIJAH CHILDS LN
CITY ICENTERVILLE STATE MA ZIP 1026322112 I TEL
FAX CELL 1 1 EMAIL ICAPEANDISLANDSPLUMBING@GMAIL.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
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r
CITY/TOWN *-ett Do MA DATE 2 Z PERMIT #
JOBSITE ADDRESS 333 fi ZCA-SA NI S1 L EL 1 OWNER'S NAME CON 14
OWNER ADDRESS 3 LEA SAN T S T R Y CT TEL61-)� i(P'VO IT FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL -
PRINT a_d to t- kiS hi' H-044.
CLEARLY NEW: 0 RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
FIXTURES Z 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER f
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK I
LAVATORY 3
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET I
URINAL
WASHING MACHINE CONNECTION j
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. YES [ i NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [2f. 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 ar 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 • - e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBERS NAME CO C1' ILLS . TA Ali/ 0 LICENSE # br Z " SIGNATURE
114(49
MP 17g, JP E CORPORATION ❑ # PARTNERSHIP ❑ # LLC ( #
COMPANY NAME AGtM I A�"�" ��-til l G �� � LL-C ADDRESS �% fc 13
crrYSA6141.a C Tacit STATEWt ZIP 10Zs197— TEL
FAX CELL 6-DP ", • O i 3 EMAIL CAk rr 1D.�5 t,fi/1l,Dc -PL '+G 6rA1 AiA/