HomeMy WebLinkAboutBLDP-19-002741 - - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 11/6/18 PERMIT# BLDP-19-002741
JOBSITE ADDRESS 17 BOXWOOD CIR VILLAGE OWNER'S NAME KENT JOSEPH N
P OWNER ADDRESS KENT SANDRA S 17 BOXWOOD CIR YARMOUTH PORT, MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL CI
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE 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 1
DRINKING FOUNTAIN
FOOD DISPOSER 1
FLOOR/AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK 1
LAVATORY 1 1
ROOF DRAIN
SHOWER STALL t
SERVICE/MOP SINK 1
TOILET 1 2 1
URINAL
WASHING MACHINE CONNECTION 1
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 Richard Olsen LICENSE#166 SIGNATURE
MP El JP ❑ CORPORATION ❑# 2166 PARTNERSHIP ❑# LLC ❑#
COMPANY NAME The Hokum Rock Corporation ADDRESS 357 Hokum Rock Rd
CITY Dennis STATE MA ZIP 02638 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES ,I
Yes No
THIS APPLICATION SERVE AS THE El El
DCDRIIIT
FEES$ PERMIT#
MV/3 c0 " PLAN REVIEW NOTES