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Home My WebLink AboutBLDP-22-006647 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t f CITY YARMOUTH —I MA DATE 5/18/22 PERMIT# BLDP-22-006647 1 );.l JOBSITE ADDRESS 52 ELLIS CIR OWNER'S NAME Gayle Williams P OWNER ADDRESS 52 ELLIS CIR YARMOUTH PORT,MA 02675-1335 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El 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 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 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,PL EASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY Cl 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 tie 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 perrrit 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 Richard Olsen LICENSE 10335 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RICHARD P OLSEN ADDRESS PO BOX 2026 CITY DENNIS STATE MA ZIP 026385026 TEL FAX CELL EMAIL office@olsenplumbing.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yee No THIS APPLICATION SERVE AS THE ❑❑ FEESS PERMITS PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK W1S _. 0�° CITY (�!CM �(CjMA DATE Z`Z5) �jLZ i PERMIT # Gt co Li JOBSITE ADDRESS _•Le �CtS �� C(,� C 1 OWNER'S NAME4C,Mle j 10 i UM.S i P OWNER ADDRESS TELLUS.261 FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL 7 EDUCATIONAL E RESIDENTIAL PRINT EX1 CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES❑ NOD FIXTURES 1 FLOOR-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - .—In— -----1r ,. .... . CROSS CONNECTION DEVICE „,.. _. DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM - r-- DEDICATED GREASE SYSTEM !` DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM ._ DISHWASHER - DRINKING FOUNTAIN FOOD DISPOSER r_ _ ... _ l y; it , iI FLOOR /AREA DRAIN ' - -- , _. INTERCEPTOR (INTERIOR) - KITCHEN SINK _,.... �.._.. LAVATORY ROOF DRAIN SHOWER STALL _., SERVICE l MOP SINK } TOILET URINAL _ WASHING MACHINE CONNECTION I,. HEATER ALL TYPES . a---- 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 i NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE DF 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 CHECK ONE ONLY: OWNER "" AGENT I hereby certify that all cf the details and information I have submitted or entered regarding this application are true and ac u too the ; st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co c w- 4 e t'ovisio he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Richard Olsen � .._.;.. _.-.._ _ LICENSE # M10335 l_ NATURE MPF JP 1 _....,. CORPORATION i # 2166 PARTNERSHIP; #! I JLLCfl# COMPANY NAME Olsen Plumbing & Heating ; ADDRESS P.O. Box 2026. 357 Hokum Rock Road L_ CITY Dennis -�-....---.— STATE ZIP 02638 TEL 1508.385-5290 I` -- --- - - ._ MA I FAX 508-385-6963 CELL EMAIL CGS 1 Ce O , QL 1io H. i