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Home My WebLink AboutBLDP-23-000471 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u =`_% CITY YARMOUTH MA DATE 7/28/22 PERMIT# BLDP-23-000471 JOBSITE ADDRESS 423 NORTH MAIN ST OWNER'S NAME GORDON CAROL A(LIFE EST) P OWNER ADDRESS 423 NORTH MAIN ST SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:D PLANS SUBMITTED: YES El NO❑ FIXTURFS • 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 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❑ 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 Anson Celin LICENSE 3R655 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ANSON CELIN ADDRESS 26 Capt.Blount Rd CITY South Yarmouth STATE MA ZIP 02664 TEL FAX CELL EMAIL ansoncelin@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEESS PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t...,77)-' CITY 5G.A ��/r r� MA DATE !' Z. 'Z � PERMIT# JOBSITE ADDRESS (i 7-3 No ii /M OWNER'S NAME /1 S 7.-- civie.i.n POWNER ADDRESS L'JZS A0,4%, /'7 -ifJ f� TEL 6;1/"3/ ? 1 FAX TYPE OR OCCUPANCY TYPE `COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL J PRINT k CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:E PLANS SUBMITTED: YES ❑ NO❑ FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 I 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 • DRINKING FOUNTAIN ' FOOD DISPOSER - - FLOOR!AREA DRAIN • INTERCEPTOR(INTERIOR) KITCHEN SINK n LAVATORY R : C E I-V- E ~ ROOF DRAIN r SHOWER STALL UL 4 7 SERVICE 1 MOP SINK _ TOILET " Rl1IliI(PING L.LPAR I MEN1 URINAL 1 tsy . j WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING OTHER r r— INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES O 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY (tir 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. T CHECK ONEONLY: OWNER 1� ❑ AGENT 11 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 accuiate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be In 7c 'ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` / ,I PLUMBER'S NAME LICENSE#` Z.C-S 5-. SIGNA E MP❑ JP(r CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME C51 l't(1 Outl/16,re 5 ADDRESS 2-6 Cc f' "-' Cot,` "e0 CITY 50 l,,t4 "( W STATE ill is ZIP Ol-G( ( TEL 5'0S 72.-4 G-neg FAX CELL EMAIL AAL v''t Cd I_;cle LEA fl ail• C 0'4' C(C i O? 56) ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • •