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HomeMy WebLinkAboutBLDP-23-006127 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK --- n CITY YARMOUTH MA DATE 5/5/23 PERMIT# BLDP-23-006127 JOBSITE ADDRESS 482 BUCK ISLAND RD OWNER'S NAME ITOWN OF YARMOUTH P OWNER ADDRESS RECREATION DEPT 1146 ROUTE 28 SOUTH YARMOUTH,MA 02664-4463 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO m FIXTURES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN 1 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 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 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 'Brian Moura I LICENSEI30822 SIGNATURE MP ❑ JP © CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME IBrian A Moura I ADDRESS 1609 UNION ST CITY IE BRIDGEWATER I STATE IMA I ZIP 1023331516 I TEL I FAX ( I CELL I I EMAIL I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =ter_ CITY yam- MA DATE 5/51 z 3 6/ P z� -v® 7 JOBSITE ADDRESS l�c�c�C Z�Sic 1L �ct OWNER'S NAME "tot,— Y4rw,cv-N OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 1j" EDUCATIONAL El RESIDENTIAL El PRINT ^/ CLEARLY NEW:Ltd RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES 2110❑ FIXTURES Z FLOOR—I 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET RECEiVE D URINAL WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES MAY O 2023 WATER PIPING OTHER 35iLa NC; PA rMi✓N7 3y INSURANCE COVERAGE: �/ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Cs'T NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE E 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 CHECK ONE ONLY: OWNER ❑ 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 `�rtr.r► /�a�r� LICENSE# ���% �/ 3o$ZZ SIGNATURE MP❑ JP Ll CORPORATION❑# PARTNERSHIP❑# LLC COMPANY NAME �fi. ,M�,«. R{10.4 411 E,} .,1.3 ADDRESS 62©( CITY g Et-1 ��k,{-eAr STATE /A ZIP 0 7_333 TE a �—/ �t1�/ �5a� �-/6�y FAX CEL /Q EMAIL re7ovro b r... ,rJ r,.,0.t Lam