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HomeMy WebLinkAboutBldp-22-001632 /. v. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK L. w c, CITY YARMOUTH MA DATE 9/21/21 PERMIT# BLDP-22-001632 1b I I - a JOBSITE ADDRESS 2 WHITES PATH t! z ) ��• I a-. OWNER'S NAME TWO AND TWELVE WHITES PATH P OWNER ADDRESS 111 WHITES PATH SOUTH YARMOUTH,MA 02664 LLC, TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES z FLOORS-4 RSM 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL . WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING • OTHER 1 _ OTHER DESCRIPTION:replace p-trap INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY 0 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 (Benjamin Diamantopoulos LICENSE'5496 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME BENJAMIN DIAMANTOPOULOS ADDRESS 25 ANTHONY RD CITY W YARMOUTH STATE MA ZIP 026733776 TEL I FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES 14 r' ` MASSACHUSETTS UNIFORM APPLICATION FOR A PE IT TO PERFORM PLUMBING WORK n»V7L.a �— CITYJThOt,27ltMA DATE PERMIT# w JOBSITE ADDRESS /Z --/ It) 9i )91:_7IWNERSt7- NAME POWNER ADDRESS _ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:gl''/ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 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/OIUSAND 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 • A �-� - ROOF DRAIN SHOWER STALL i I SERVICE/MOP SINK i 4_ , TOILET t URINAL Et ' � 1� =fl 'iP•'� T I WASHING MACHINE CONNECTION , - WATER HEATER ALL TYPES WATER PIPING ! OTHER '� ��f� f L - /� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 21 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF GE 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 t Massachusetts General Laws,and that my signature on this permit application waives this requirement. . CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT L'J I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a curate 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 't all Pertinent provision of the Massachusetts State P mbing Code and Chapter 142 of the General Laws. PLUMBER'S NAM 171/1—it/fIfIL!7b/O LtC ENSE# /,—(-7/9" SIGNATURE MP JP®.--I- CORPORATION❑# PARTNERSHIP 0.# A C 0# COMPANY N E 6/(/V/�'!�� Pc../-1/ ADDRESS 2, /t/(/ mA.) CITY i` (/e �,c� �j STATE / "//r ZIP V�/ TE 6 9.5 FAX CELL EMAIL /Z 65 9x7/ .. 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 4,1 /.