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Home My WebLink AboutBLDP-21-006940 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 6/1/21 PERMIT# BLDP-21-006940 JOBSITE ADDRESS 15 KATES PATH VILLAGE OWNER'S NAME HOPKINS REGINA M n OWNER ADDRESS 1201 BRADDOCK PL UNIT 614 ALEXANDRIA,VA 22341 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 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 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 Anson Celin LICENSE 3f2655 SIGNATURE MP ❑ 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 Yea No THIS APPLICATION SERVE AS THE PERMIT ❑ FEES$ PERMIT# PLAN REVIEW NOTES • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =1-{ CITY V!Arm h 4.1 gi c MA DATE 5( -21 PERMIT# JOBSITE ADDRESS fr 5<4- ?c$ OWNER'S NAME Fti C",C1.G1 •� ��ti n� OWNER ADDRESS ( S t' ?c,-6X TEL1-V C(Z---Gq FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL PRINT / CLEARLY NEW:D. RENOVATION:��1 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR-F BSM 1 2 3 4 5 6 7 B 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 SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) -' KITCHEN SINK • LAVATORY 7 _ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET L URINAL WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES 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 e NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY [7r 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 4 Massachusetts General Laws,and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER El AGENT ❑ SIGNATURE OF OWNER OR AGENT `I 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. A#11) Y\-- PLUMBERS NAME LICENSE#3ZC SIGNATURE MP ❑ JP Id CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME Alc.✓) C(j,- ADDRESS Z C40- u I n !`` CITY <5„s- ggImd/t1 STATE /14A ZIP (... TEL 50 _2(_,(0-L r/CZ__ FAX CELL EMAIL Arr,cyl.CC(;n 6)61a.(/o0• C001 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 • •