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HomeMy WebLinkAboutBLDP-23-001718 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY IYARMOUTH I MA DATE 9/29/22 PERMIT# BLDP-23-001718 I '>' JOBSITE ADDRESS 14 RIVER DR OWNER'S NAME ITUREK MARY V TR P OWNER ADDRESS (THE MARY V TUREK FAMILY TRUST 4 RIVER DR SOUTH YARMOUTH,MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: m RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO m FIXTURES FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE 2 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 4 3 ROOF DRAIN SHOWER STALL 2 SERVICE/MOP SINK TOILET 3 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 WATER PIPING 1 1 1 OTHER 1 OTHER DESCRIPTION:rinsing station outside INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES m 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 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 (Matthew Coleman LICENSE 3#368 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME (matt coleman plumbing and heating I ADDRESS 15 college st CITY (west yarmouth I STATE (MA I ZIP 102673 I TEL 19788854343 FAX I I CELL I I EMAIL I