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HomeMy WebLinkAboutBLDP-21-000807 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 8/19/20 PERMIT# BLDP-21-000807 JOBSITE ADDRESS 6 FOREST GATE VILLAGE OWNER'S NAME KOSAK BERNARDINE P OWNER ADDRESS 6 FOREST GATE YARMOUTH PORT,MA 02675-1459 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑v PRINT CLEARLY NEW.❑ RENOVATION:U 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER _WATER PIPING 1 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Gregory Selfe LICENSE 26714 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME GREGORY A SELFE ADDRESS 141 SPRINGER LN CITY IWESTYARMOUTH STATE MA ZIP 1026734930 TEL FAX CELL I I EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT n 0 FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r A m ' �lMA DATE { a ao PERMIT # Z / ,r� ., �a�E_ CITY OWN A E ,LjL1�� ��,/" JOBSITE ADDRESS 6 Fog-eft 6Pte, g' OWNER'S NAME SI,t CS Prr OWNER ADDRESS 6 Re Sf- 6a�G K n QSr,`,��, TE s'0 )c *476a, FAX 0 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:K, REPLACEMENT: ❑ PLANS SUBMITTED: YES n NO n FIXTURES Z FLOOR-4 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 1? Er DISHWASHER V DRINKING FOUNTAIN — tr;;;G FOOD DISPOSER 13 2o�o FLOOR / AREA DRAIN $uf��iN J INTERCEPTOR (INTERIOR) E r R T KITCHEN SINK -_ E rV r LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 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. YESF, NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M 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. 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 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 Perlin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 6E0R7CtikFt-- LICENSE # N 71 GNA RE MP ❑ JP CORPORATION El # PARTNERSHIP n # LLC ❑ # DgA COMPANY NAME erc S�1 �- erne� Set"`� _ ADDRESS L( ( CPC `^ G� L A-rl r- Y PL "� � CITY 6 ral04.11, STATE CAA _ ZIP °a4 `13 TEL(5'O %)) g`/c1 ?tf FAX CELICEvern' - f(i 3 `r EMAIL self fsr`a e- h eo. cowl pLu M&S Ai 5,, eh- 0/9I/2 z a c