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HomeMy WebLinkAboutBLDP-23-004152 UNIT A —` - a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 11/4 CITY YARMOUTH MA DATE 1/26/23 PERMIT# BLDP-23-004152 JOBSITE ADDRESS 737 ROUTE 28 OWNER'S NAME Jania De Silva P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURES z FLOORS 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 2 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 Joseph Halloran LICENSE 13984 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME JOSEPH M HALLORAN ADDRESS 129 Forest Glen Rd I CITY Hyannis STATE IMA I ZIP 1026012537 I TEL I I FAX I I CELL I I EMAIL Isowdaw g@comcast.net • _ MASSACHUSETTS UNIFORM APPLICATION FOR PE T TO PERFORM PLUMBING WORK 1 CITY \/,"//L,M c-v/. �r , / MA DATE l Z Z 3 PERMIT* 2-3 — e/ / f Z JOBSITE ADDRESS 7 37 4 Al. d OWNER'S NAME 1��r g /-24�l ,�► P OWNER ADDRESS .5) hTEL a/7-757 2;10 ZX TYPE OR OCCUPANCY TYPE COMMERCIAL f EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[ J PLANS SUBMITTED: YES 0 NO❑ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 I 5 6 I 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET - _ URINAL I WASHING MACHINE CONNECTION - WATER HEATER ALL TYPES • WATER PIPING { OTHER INSURANCEI have a current liability insurance policy or its substantial equivl nt which meets the requirements of MGL Ch.142. YES ErN0 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY 12'. 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 A ENT 0 SIGNATURE OF OWNER OR AGENT k`l I hereby certify that all of the details and information I have submitted or entered regarding this application are true a ac and that all plumbing work and installations performed under the permit issued for this application will be in comp!' Peg y of the Massachusetts State Plumbing C de and hater 142 of the General Laws. on of the PLUMBER'S NAME1r'dff9 4lk" -4 ' LICENSE # SIGNATURE G' MP[v]" JP❑ CORP TIO ❑# PARTNERSHIP❑.# LLC 0#/ / ' f COMP? NAME GSi o f i1/I(7/ ti ADDRESS ;2 C c / / 1'� �5'�a l?�v g O', CITY tii STATE M6 ZIP ci2 'CC"/ TEL S � � 2-0- �l �'. FAX CELL EMAIL o'wc/