Loading...
HomeMy WebLinkAboutBLDP-23-004806 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK c7 CITY IYARMOUTH MA DATE 3/1/23 PERMIT# BLDP-23-004806 Alb i _4 JOBSITE ADDRESS 1185 SEAVIEW AVE OWNERS NAME GEORGE NORWOOD P OWNER ADDRESS KELLY NORWOOD 69 PINE TREE DR METHUEN 018440000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW: m RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO m FIXTURES 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 1 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 1 URINAL WASHING MACHINE CONNECTION 1 _WATER HEATER 1 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© 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 Kosta Laci LICENS41+6529 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME KOSTA LACI ADDRESS 612 WASHINGTON ST CITY BRAINTREE STATE MA ZIP 021845755 TEL FAX CELL 1 EMAIL isa. s?)" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i�' _p._CLT --,�OJ i'1'11pv+1.' MA DATE 3 - / 3 _ PERMIT#________________ IV 0 1 SITE ADDRESS 18 S S� v I 1 V a OWNER'S NAME OWNER-AD�RESS BOIL G DEPARTMENT TEL FAX By s's—' - - ---- TYPE COMMERCIAL PRINT ❑ EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:NEW:151 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 FIXTURES 1. FLOOR-+ BSM 1 I 2 3 BATHTUB t 4 5 6 7 B' 9 10 11 12 13 14 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 I LAVATORY ROOF DRAINlc .1_ SHOWER STALL SERVICE/MOP SINK TOILET i URINAL a� WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING 1. (; OTHER `L2J N INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO 0 0- IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POUCY A 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 i Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT 0 lki 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 mph ce th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 4�0 36 Lo�` LICENSE# 16 S— 1 SIGNATURE MP 0 JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0# COMPANY NAME �,Letc..t C�I�w,b► g.�ie+Nt L . C ADDRESS ()I Wail Ii4 CITY 13 HGlvt 7 STATE CI�- ZIP 0 LI g TEL�TEL et 7--t6 337� FAX CELL EMAIL /I b C(`7'5^0 A _tsid I (�