HomeMy WebLinkAboutBLDP-22-001000 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY YARMOUTH MA DATE 8/23/21 PERMIT# BLDP-22-001000
N .
JOBSITE ADDRESS 20 GREENLAND CIR OWNER'S NAME marlene fuentes
P OWNER ADDRESS 20 GREENLAND CIR YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El
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
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 1
WATER PIPING
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liabil t�insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE 0=INDEMNITY El BOND El
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 David Michalowski LICENSE 1)5722 SIGNATURE
MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME DAVID R MICHALOWSKI ADDRESS 22 GREENLAND CIR
CITY YARMOUTH PORT STATE MA -I ZIP 026752183 TEL
FAX CELL EMAIL davemichalowski@yahoo.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEESS PERMITH
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
____ CITY yi ori✓1 a MA DATE d7/• /V-/ PERMIT# VL- t boo
JOBSITE ADDRESS ���r-r,•i//as" 6 ✓C/e OWNER'S NAME A 0.,"-11 fi't f Z
POWNER ADDRESS a-2, G'//'CzJio-. C, Je TEL' Y72i s7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT �.,/
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:CV PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z 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
ROOF DRAIN '• E i E V E D�
SHOWER STALL
SERVICE/MOP SINK
TOILET L r] 2 LOl1
URINAL
WASHING MACHINE CONNECTION tit Di VG D HARTMENT
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❑ NO)50
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY ❑ 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 ignature on this permit application waives this requirement.
�Q CHECK ONE ONLY: OWNER AGENT ❑
SIGNATU 0 N OR AGENT
I hereby certify that all of the de s 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 Pertinen provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� /e
o L./PLUMBER'S NAME 27' i� / 1440/aG.ijk_j LICENSE# SIGNATURE
MP Et JP ig/�j / CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME// cho/04-ccie.2 if/v/si 4 ant,//r&o 4, ADDRESS 12-. ✓ CCA /xn`-t �-/r c/e
CITY l�iai7yiev� �.� STAT&47'V / ZIP 7 TEL 7 2 99 7. 7
FAX CELL EMAIL
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