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Home My WebLink AboutBLDP-23-000889 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK u '= CITY YARMOUTH MA DATE 8/18/22 kPERMIT# BLDP23-000889 yi JOBSITE ADDRESS 14 DAISY LN OWNER'S NAME KOLPAK HAROLD S P OWNER ADDRESS KOLPAK LINDA T 333 SPRUCE ST CHESHIRE,CT 06410 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO Cl FIXTURFS • 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 FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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 he 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 r peter checkoway LICENSE 13417 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME ADDRESS 11 scargo hill rd 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 9-.1-Te 126--=, - f= �3 -- oP9 CITY SOUTH YARMOUTH MA DATE 8/15/22 PERMIT # J JOBSITE ADDRESS 14 DAISY LANE, S Y OWNER'S NAME HAL KOLPAK POWNER ADDRESS SAME TEL 203-819-6959 IFAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO I I FIXTURES -1 FLOOR- BSM 1 i 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - CROSS CONNECTION DEVICE . ..... 1 ,L. --q, DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM iiii t �U DEDICATED GREASE SYSTEMif- DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ,_ __ _ 1. , DISHWASHER 1 _- DRINKING FOUNTAIN FOOD DISPOSER ---11 - i , � .- FLOOR / AREA DRAIN 1 ... INTERCEPTOR (INTERIOR) KITCHEN SINK , 1 _ LAVATORY 1 .. FI L I ROOF DRAIN SHOWER STALL t, + . SERVICE / MOP SINK If TOILET 1 -1--(4-1 n________________ ,_ _ I URINAL '�� WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER._ i!w I. i_ INSURANCE COVERAGE: I have a current IiabiliYinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES v NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L' OTHER TYPE OF INDEMNITY ❑ BOND ED 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. CHECK ONE ONLY: OWNER AGENT 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 o ' - .-st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al/' : - t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - , PLUMBER'S NAME R Peter Checkoway ,..JLICENSE # 13417 $ SIGH URE MP i JP CORPORATION El PARTNERSHIPS# LLCEJ# COMPANY NAME! Checkoway Enterprises I ADDRESS 11 Scargo Hill Rd _ _ CITY Dennis STATE MA ZIP 1-62638 I TEL 508-385-1911 FAX 508-385-6858 CELL 508-735 9993 EMAIL [checkent@comcast net L s .. a ? r .�� aJ 7 7- t. .F Wyi