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HomeMy WebLinkAboutBLDP-21-001149 effdo I" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 9/3/20 PERMIT# BLDP-21-001149 JOBSITE ADDRESS 20 BUTLER AVE OWNER'S NAME ENGLISH DONNA A P OWNER ADDRESS CIO VINCENT ENGLISH 2 LAN RD SANDWICH,MA 02563 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES _I FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 79, 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❑ 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 Dennis Earle LICENSE 1 795 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Dennis A Earle ADDRESS PO BOX 876 CITY SANDWICH STATE MA ZIP 025630876 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ ¢iC 913 O FEES$ PERMIT# PLAN REVIEW NOTES ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .--- -., .4 9 ` • CITYQST 7�Q IUIL LDS JOBSITE ADDRESS 2Q 1 UTL 2, Ave 4' mA RATE OWNER'S NAME C'R R� �i eA/T Y p OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:D REPLACEMENT PLANS SUBMITTED YES 0 NO D FIXTURES 1 FLOOR-+ BM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I r DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOUJSAND SYSTEM , DEDICATED GREASE SYSTEM - DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ DRINKING FOUNTAI+! FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK - j LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK I ;:" 1 ' ° i . TOILET , URINAL j r 1 - " Sty !t 2i�;•F WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ), OTHER 4grp/t 60,6.er. _ i �" ._�.• } INSURANCE COVERAGE: - I have a current substantial policy or• santial equivalentwhich meets the requirements of MGL Ch.142. YES NO ❑ I YOU CHECKED YES,PLEASE INDICATE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY OTHER TYPE OF INDBhtNTY 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 permk application waives this reqUitiMera, CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the dotage and Intonation a that l plumbing State have submitted or enNaed regal Via appkation are and accurate the beet of my Image M State performedwatt and installations under the permit Issued for this application wl6 be in ail provision of the Plumbing Code and Chapter 142 of the General Laws, PLUMBER'S NAME UCENSE# /s��s- SIGNATURE MP❑ JP 14r CORPORATION❑# PARTNERSHIP❑# LLC 0# COMPANY NAME e n n ►.5 �k L . P f)-4 ADDRESS /$Z r i d CITY SN-or/i?l(/kv x sTATE-) 3P ©as-‘-. S TEL .9P (.?) ,Cs</9 FAX CELL I' T 6' i .YLI EMAIL 40 -10-/a GKS