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Home My WebLink Aboutbldp-21-007473 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK g9 CITY YARMOUTH MA DATE 6/23/21 PERMIT# BLDP-21-007473 41. a 1=f-4/ JOBSITE ADDRESS 204 ROUTE 28 OWNER'S NAME North Eastern Conference of S.D.A P OWNER ADDRESS MA 02347 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El 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 SERVICE/MOP SINK TOILET 1 URINAL 1 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 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 El CORPORATION ❑# I I PARTNERSHIP ❑# I I Lc ❑# COMPANY NAME JANSON CELIN I ADDRESS 126 Capt. Blount Rd CITY (South Yarmouth I STATE IMA I ZIP 102664 I TEL I FAX I I CELL 1 I EMAIL Iansoncelin@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK --MCITY V( Cat I11 O 1 MA DATE Z - PERMIT# r JOBSITE ADDRESS 23 Li V- Z ? OWNER'S NAME ' O C01-i✓lC& POWNER ADDRESS 4 264 VZd- Z'K TEL r7 'I-7?-2-Ail FAX TYPE OR OCCUPANCY TYPE COMMERCIAL'S EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:O. RENOVATION:❑ REPLACEMENT:[r PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR—+ BSM 1 2 3 4 5 6 7 6 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 1 DISHWASHER • J DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN — INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 7. . ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK i TOILET ia URINAL F . 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 NO 0 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 ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i` Massachusetts General Laws, and that my signature on this permit application waives this requirement. rr --.. CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT t•U 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 LICENSE# An, ' GN 3 Z c_ 5.5_ SIGNATIXE MP❑ JP(Pd CORPORATION❑# PARTNERSHIP El.# LLC❑# COMPANY NAME A►�� C61 i'f\ ADDRESS 7 c, C� / �-�n �1c�nrrt 12,p CITY vi,` 1 u GV/1'1csv / STATE 4/ I ZIP C5246(( TEL d ---7_, 2 FAX CELL /� + EMAIL A-ics Ci'1 OA CE Ji zi ¢�. c�� 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 • i • i . - 1