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HomeMy WebLinkAboutBLDP-23-001853 44. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I MA DATE 110/6/22 I PERMIT# BLDP-23-001853 y, CITY IYARMOUTH I I ` JOBSITE ADDRESS 180 ROUTE 28 OWNER'S NAME IKRASION LLC OWNER ADDRESS 'CIO MESIALIDES KONSTANTIA 128 GLENEAGLE DR CENTERVILLE,MA 02632 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL III RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOORS—V 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 1 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 WATER PIPING OTHER 2 OTHER DESCRIPTION: INSURANCE COVERAGE: YES El NO ❑ 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. PLUMBER'S NAME (Robert Lalime LICENS410701 SIGNATURE MP JP CORPORATION ❑# I I PARTNERSHIP ❑# I LLC ❑# _.-- © ❑ COMPANY NAME IBCL PLUMBING I ADDRESS 1575 Main Street CITY IMashpee I STATE IMA ZIP 102649 I TEL I FAX I 1 CELL 15082920374 EMAIL Inane 12;1Jcf 2 W r‘0-0c ::) MASSACHUSETTS UNIFORM APPLICATION OR A PERMIT TO PERFORM PLUMBING WORK �= CITY viat-h O C? l L`="r Tl MA DATE f0 7 Z3 ��r� nY S Z PERMIT# JOBSITE ADDRESS O o 1l A I N s I Ira 0 OWNER'S NAME (2 ?L Sv/y"?,� ? POWNER ADDRESS . TEL 50e- 6r(-0 4FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E' EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:[ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0 FIXTURES 7. FLOOR-► 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/OILISAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ DISHWASHER .o'"4'(f-f;AL N - DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) ECFIVECI KITCHEN SINK LAVATORY • ROOF DRAIN c 42 SHOWER STALL - _ - SERVICE/MOP SINK IL TOILET BUDING GEPAR`MEN URINAL T—� —r - i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING OTHER a INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I NO 0 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 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the r Massachusetts General Laws,and that my signature on this permit apQlication waives this requirement. CHECK ONE ONLY:: OWNER SIGNATURE OF OWNER OR AGENT 0 AGENT El L-1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur. and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi • . b ' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A. i � my knrnn�ledge PLUMBER'S NAME LICENSE# 370 MP JP 0 I SIGNATURE &C LCO ORATION�# PARTNERSHIP❑.# LLC 0# COMPANY NAME (A) imli A, c CITY-�n �i3 ADDRESS 57�/��p� G�,vim.. �T STATE VA ZIP 0 C 6 7 9 TEL FAX CELL 5�j�" 2--(�3-Z Y EMAIL