HomeMy WebLinkAboutBLDP-23-005063 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/15/23 PERMIT# BLDP-23-005063
1.
JOBSITE ADDRESS 500 ROUTE 6A OWNER'S NAME FITZGERALD SHEILA M TRS
OWNER ADDRESS SMF REALTY TRUST PO BOX 535 YARMOUTH PORT 02675-0000 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
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
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTE
DISHWASHER 2
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 2
LAVATORY 4
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 3
URINAL
WASHING MACHINE CONNECTION 2
WATER HEATER , 2
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 permi7 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 Eugenijus Jagminas LICENSE 1690 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME I UGENIJUS JAGMINAS ADDRESS 34 ELIJAH CHILDS LN
CITY CENTERVILLE STATE MA ZIP 026322112 TEL
FAX 7 CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ El
FEES$ PERMITS
PLAN REVIEW NOTES
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MASSACHUSETTS UNIFOR A PLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-"= CITY \' GBH MA DATE 1 4/73 Fia IT#
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JOBSITE A6'DRESS SCl, /2 r 6 OWNER'S NAME i ��'�e2%�C
POWNER ADDRESS // TEL . FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ll-----
PRINT
CLEARLY NEW:❑ RENOVATION: [n.REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER : •~ • ,
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK '2 _ _
LAVATORY 4 T •
ROOF DRAIN - ,
SHOWER STALL a. _ _ _
SERVICE/MOP SINK _
i TOILET J
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 2 _
WATER PIPING
OTHER
I
i 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
LIABIUTY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY 0 BOND ❑
i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
r. CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
Qk! I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura to the:. of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian ertin provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER'S NAME LICENSE# �--- GNATU
MP JP❑ CORPORATION 0# PARTN HIP❑.# LLC❑#
COMPANY NAME CI )/ /l� •)4 E ADDRESS (; . 43 C3/°/(o7
CITY �' l� �J 7 STATE �1 ZIP D c-P cL TEL TEL J-d 8- e8 9?
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES '•'
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Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ (l
FEE: $ PERMIT #
PLAN REVIEW NOTES
1