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HomeMy WebLinkAboutBLDP-23-005609 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 'YARMOUTH I MA DATE 14/10/23 ( PERMIT# BLDP-23-005609 JOBSITE ADDRESS 11050 ROUTE 28 I OWNERS NAME IXC 1050 ROUTE 28 REALTY LLC OWNER ADDRESS IC/0 CAPE MANAGEMENT TEAM LLC 169 MAIN STREET STONEHAM 02720-0000 I TEL I P TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES NO m =IXTURES 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN 12 INTERCEPTOR(INTERIOR) 1 KITCHEN SINK LAVATORY 2 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK 1 TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: YES© NO 0 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. 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 IBRIAN COUTO LICENS416316 SIGNATURE MP El JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME IBRIAN K COUTO I ADDRESS 142 OAK ST APT 1 CITY FALL RIVER I STATE IMA ZIP 1027204913 I TEL I IFALL i FAX I CELL I I EMAIL Ibriancoto@ymail.com • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • C :� v r r (vv..�:� MA DATE A P 02 J BS1rE ADDRESS (b5'r - 2.cV OWNER'S NAME I __ \ • tit t ;NG PART, OWNERADDRESS - TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Er-- EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:0 RENOVATION:O —REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 FIXTURES 1. FLOOR-1. BSM 1 2 3 4 5 6 7 8 J 9 10 11 12 13 4 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 kat. 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 UABILITY INSURANCE POLICY E 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 i Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 Z SIGNATURE OF OWNER OR AGENT L:I 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 LICENSE# (( ---'STNATURE MP JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME .1 c V ADDRESS \,,V.ir„-\, 4.�� CITY v - Jew An STATE !" ok.. ZIP r0-2- 7eD TEL FAX CELL'-- Q.Cf Z-- Z-'te?'i EMAIL