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HomeMy WebLinkAboutBLDP&G-22-000920 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 8/17/21 PERMIT# BLDP-22-000920 JOBSITE ADDRESS 2 WILDFLOWER VILLAGE OWNER'S NAME FOERSTER FREDERICK H III P OWNER ADDRESS FOERSTER ANNE L 2 WILDFLOWER VILLAGE YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET , 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 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 0 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. 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 richard olsen LICENSE 166 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME [Olsen plumbing corperation inc ADDRESS •357 Hokum Rock Road CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX -I CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES S PERMIT# PLAN REVIEW NOTES 4' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4_` CITY YARMOUTH 7 MA DATE August 17, 2021 PERMIT# BLDP-22-000920 lbe a_ice �- rs� JOBSITE ADDRESS 12 WILDFLOWER VILLAGE OWNER'S NAME FOERSTER FREDERICK H III G OWNER ADDRESS FOERSTER ANNE L 2 WILDFLOWER VILLAGE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: El PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER 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 Massachu:.etts State Plumbing Code and Chapter 142 of the Gereral Laws. PLUMBER-GASFITTER NAME richard olsen LICENSE # 2166 SIGNATURE MP © MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION [] # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME: Llsen plumbing corperation inc ADDRESS. 357 Hokum Rock Road. CITY Dennis STATE MA ZIP 02638 TEL 5083855290 FAX ] CELL EMAIL S310N M3IA321 NHId #1I1A1213d $:33d ❑ ❑ 1IINi13d 3H1 SV SAS NOI1VOIlddV SIH1 oN saA SO LON NO1103dSNI TAU AINO 3Sfl a0103dSNI Nod 30Vd SIH1 SO LON NO1103dSNI SVO HOl0N