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HomeMy WebLinkAboutBLDP-19-005231 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u = CITY YARMOUTH MA DATE 3/18/19 PERMIT# BLDP-19-005231 JOBSITE ADDRESS 5 CARRIAGE LN OWNER'S NAME SANDY SIDE CORP P OWNER ADDRESS P 0 BOX 525 YARMOUTH PORT,MA 02675 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 1 2 1 CROSS CONNECTION DEVICE 1 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 7 4 ROOF DRAIN SHOWER STALL 3 1 SERVICE/MOP SINK 2 2 TOILET 2 3 1 URINAL WASHING MACHINE CONNECTION 1 1 WATER HEATER 2 WATER PIPING OTHER 1 OTHER DESCRIPTION:Bar sink 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 0 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 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 Richard Olsen LICENSE 2166 SIGNATURE MP 0 JP ❑ CORPORATION ❑# 2166 PARTNERSHIP ❑# LLC ❑# COMPANY NAME Olsen Plumbing&Heating ADDRESS PO BOX 2026 CITY Dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL 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 N1 CITY YARMOUTH MA DATE 3/18/19 PERMIT# BLDP-19-005231 JOBSITE ADDRESS 5 CARRIAGE LN OWNER'S NAME SANDY SIDE CORP P OWNER ADDRESS P 0 BOX 525 YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES -; FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 2 1 CROSS CONNECTION DEVICE 1 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 7 4 ROOF DRAIN SHOWER STALL 3 1 SERVICE/MOP SINK 2 2 TOILET 2 3 1 URINAL WASHING MACHINE CONNECTION 1 1 WATER HEATER 2 WATER PIPING OTHER 1 OTHER DESCRIPTION: Bar sink 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 Richard Olsen LICENSE 2,166 SIGNATURE MP 0 JP ❑ CORPORATION ❑# 2166 PARTNERSHIP ❑# LLC ❑# COMPANY NAME Olsen Plumbing&Heating ADDRESS PO BOX 2026 CITY Dennis STATE MA ZIP 02638 TEL FAX CELL EMAIL I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El 1d-/Z ✓`5 FEES$ PERMIT# L1 f g PLAN REVIEW NOTES AcW