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HomeMy WebLinkAboutBLDP-23-003798 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 1/12/23 PERMIT# BLDP-23-003798 I' • JOBSITE ADDRESS 80 BAXTER AVE OWNERS NAME Neal Checka P OWNER ADDRESS 80 BAXTER AVE WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES z FLOORS-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 SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 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 El 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. PLUMBERS NAME lome jussila LICENSE 3t1971 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 84 Bog Lane CITY WEST HARWICH STATE MA ZIP 02645 TEL FAX CELL 5087768943 EMAIL Iornejussila@hotmail.com IFtr ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES; PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK .1V-,• CITY Jeci 4 0,2 0:)-A MA DATE / -2,0,9..3 PERMIT# 13 - 3-79V JOBSITE ADD SS SO & I4I AC,'e OWNER'S NAME/U / &.n C1 ecjc OWNER ADDRESS feT WN/ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATIONS._ REPLACEMENT: PLANS SUBMITTED: YES❑ NO2 FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 B' 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 I • DEDICATED WATER RECYCLE SYSTEM DISHWASHER / • • DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 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. YES NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY`tZ1 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. • CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat o the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in Hance with • ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE#� 1 SIGNATURE MP❑ JP' / CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPAW NAME t5J ADDRESS Vl /CM- / - CITY Ma-1BC/1 STATS!L ZIP 0o//r/� /TEL 73 FAX CELL EMAIL/ irif t/t,'�1IQ �o`fpla • (al) • 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 •