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HomeMy WebLinkAboutBLDP-23-005060 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 11/4 CITY YARMOUTH MA DATE 3/15/23 PERMIT# BLDP 23 005060 7-7 l it JOBSITE ADDRESS 4 RUNE STONE RD OWNER'S NAME YOBACCIO ROBERT J P OWNER ADDRESS YOBACCIO BARBARA 4 RUNE STONE ROAD SOUTH YARMOUTH,MA TEL 02664-1325 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURFS ..1 FLOORS—> BSM 1 2 3 4 5 6 7 , 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE 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 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER WATER PIPING 1 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ 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 John Burke LICENSE 1582 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME JOHN J BURKE ADDRESS PO BOX 866 CITY HANSON STATE MA ZIP 023410866 TEL FAX CELL 7 EMAIL NONE MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY/TOWN a-r no u. MA DATE 3 -/5-Z 3 PERMIT# 2 3 5-0 60 JOBSITE ADDRESS 11 ,v/ie 5-4 4 OWNER'S NAME / �! 5 , p OWNER ADDRESS 5P/11 C TE.Q2 }f_ �t 580 0FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL�- PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT;❑ PLANS SUBMITTED; YES❑ NO❑ FIXTURES 1 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/OIUSANI)SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTE-RCE-RTOR(INTERIOR) KITCHEN SINK / - - - LAVATORY a. ROOF DRAIN_ SHOWER STALL SERVICE I MOP SINK TOILET 1.' URINAL WASHING MACHINE CONNECTION j - WATER HEATER ALL TYPES WATER PIPING OTHER - • INSURANCE COVERAGE: I-have a current liability insurance policy or its substantial equivalent which meets the requires of MGL Ch.142. YES,t NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Est 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 CHECK ONE ONLY: OWNER Q AGENT El I hereby certify that all of the details and Information I have submitted or entered regarding this application are e accu the best of my knowledge and that all plumbing work and installations performed under the permit issued for this Massachusetts State Plumbing Code and Chapter 142 of the General Laws, application will be in with I eminent provision of the PLUMBER'S NAME .Q 14 L i LICENSE#f 5- a SIGNATURE_ MP Eh-- JP Q CO7ORITION❑# PARTNERSHIP Q# LLC �l d# COMPANY NA Un'I�%1 ADDRESS /3 / ,S CITY D`�l -rG STATE ZIP ©Z3 38 TEL _� } �" o2 y y3 Ste( CELL EMAIL