HomeMy WebLinkAboutBLDP-21-005016 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
n. CITY YARMOUTH J MA DATE 3/5/21 PERMIT# BLDP-21-005016
mil—gip. JOBSITE ADDRESS 32 COUNTRY CLUB DR OWNER'S NAME JOHNSON MARY CHISHOLM
P OWNER ADDRESS 32 COUNTRY CLUB DR SOUTH YARMOUTH,MA 02664 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
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 2
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK _
TOILET 2
URINAL
WASHING MACHINE CONNECTION 1
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 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 Kesuqs Lopez LICENSE h6301 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME KESUQS LOPEZ ADDRESS 107 Meetinghouse Rd
CITY Mashpee STATE MA ZIP 026492617 TEL
FAX CELL 7 EMAIL kees@evenflowplumbing.solutions
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FI\AI.INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT ❑ ❑
FEES$ PERMITS
PLAN REVIEW NOTES
' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Tigir'm CITY/TOWN y meIO MA DATE c215 PERMIT# QLD J1 t ✓UD�UI(o
JOBSITE ADDRESS_32 CW *Ai CA(AO OWNER'S NAME 1,1- c.i/el nicKeiln 9
.7 / TEL f / 7V)2 %01 FAX
P OWNER ADDRESS-)a-�� �i.�1�1�'Y� C�Giv,� �y'
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: XI REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NOV
FIXTURES I 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY h. ,
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
6
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES c2 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY pir 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.
CHECK ONE ONLY: OWNER El 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 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 ne.SUOTS L.97.Z LICENSE# /b. 6l SIGNATURE
MP JP 0 CORPORATION- ; CI# PARTNERSHIP 1-_]# LLC 0#
COMPANY NAME OV1 'rib t'i 10,1,,,r5ADDRESS m(}l MZeV t 1.5vvAkse pa
CITY neAV-REC STATE (`'I r, ZIP �' b
1 ��y TEL (772
FAX WA CELI('771)oC:C3 itbd EMAILj4(gt-`% 4\t-/Ot-s1-Ft u4.vlb‘t11 .` .111v
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