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HomeMy WebLinkAboutBLDP-22-006981 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 612/22 PERMIT# BLDP-22-006981 JOBSITE ADDRESS 11 CADET LN OWNER'S NAME[Carlos Ferreira P OWNER ADDRESS 11 CADET LN WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES • FLOORS—I 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/OIUSAND 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 1 SERVICE/MOP SINK TOILET 1 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,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 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 Anson Celin LICENSE 3R655 SIGNATURE MP 0 JP © CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME IANSON CELIN ADDRESS 26 Capt.Blount Rd CITY 'South Yarmouth I STATE MA ZIP 02664 TEL FAX CELL I I EMAIL Iansoncelin@yahoo.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El El nrA••R FEES$ PERMIT$ PLAN REVIEW NOTES ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Lar'h MA DATE S-31-22 PERMIT# ZZ - S$, �� Z10= ADDRESS I I �-� OWNER'S NAME C0rlcb 4rrr6lreit BL. U LDINPLPAR ,R`''1 ADDRESS t I C(434- TEL S 460--41w aY ' • •C FANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ea "- PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 FIXTURES 1 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 • t ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER i � l INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESV NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY 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 I Massachusetts General Laws,and that my signature on this permit ap?lication 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 i compliance wit all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE#s Lass- SIGNATURE MP❑ JP(?:( CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME C•C 1)c) 61Wilbi6 cv7A j' 1 ADDRESS 7 j COP I-ad1 CL ,Q CITY 4r/417 STATEM 16r ZIP 02GG TEL FAX CELL 56?3-2-Led—1-4( EMAIL A115crl CY i;i l 'Cq t itr, r 0.<#2 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES