HomeMy WebLinkAboutBLDP-22-002510 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-ita CITY YARMOUTH MA DATE 11/2/21
,w,LPERMIT# BLDP-22-002510
JOBSITE ADDRESS 30&32 MISTY LN OWNER'S NAME SLAWSKI PATRICIA
P OWNER ADDRESS 30 MISTY LN SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES NO❑
FIXTURES i FLOORS—. RSM 1 2 3 4 5 R 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
WATER PIPING
OTHER 1
OTHER DESCRIPTION:Backflow preventer
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❑ 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 at 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 at plumbing work and installations performed under the permit issued for this application will be in compliance with an Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME richard olsen LICENSE 8166 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME olsen plumbing corporation inc ADDRESS po box 2026
CITY dennis STATE MA ZIP 02638 TEL 5083855290
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