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HomeMy WebLinkAboutBLDP-23-005236 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK S CITY YARMOUTH MA DATE I3/23/23 PERMIT# BLDP-23-005236 JOBSITE ADDRESS 42 KATES PATH VILLAGE OWNER'S NAME CHAPLAN LAWRENCE R(LIFE EST) P OWNER ADDRESS 42 KATES PATH VILLAGE YARMOUTH PORT 02675-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW:0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES NO m FIXTURES .1 FLOORS-4 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 INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 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 (William Fitzgerald I LICENSE112912 I SIGNATURE MP © JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I 1 ❑# LLC COMPANY NAME 'WILLIAM G FITZGERALD I ADDRESS InCIMMI CITY ICENTERVILLE I STATE IMA I ZIP 026323228 TEL FAX I I CELL I EMAIL mrplumbrite@gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '"- "' CITY ArV '�it^ Porgy / ff�� =1= MA DATE 3(aa Ja 3 PERMI � 23_ Z3,4 JOBSITE ADDRESS a KA i PS ? OWNER'S NAME L/)rry (iA A pi; A POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IQ' PRINT CLEARLY NEW:❑ RENOVATION:Of REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 BATHTUB 14 CROSS CONNECTION DEVICE - DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND 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 _ URINAL Z j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES �' ' E WATER PIPING 1 _ OTHER r •C—C_ -:, i }f>V i 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 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY F 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. �� CHECK ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT ❑ AGENT ❑ LI I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura o the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia with ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# / Cc MP�(] JP El CORPORATION SIGNATURE CORPORATION❑# PARTNERSHIP❑.# LLC 0# COMPANY NAME flit 12 PwMj- p,j P ADDRESS ?Li/ P MI \ CITY CC'', 4' ' 1\e STATE A FAX M ZIP as 6 3 a TEL Sol? ))6- 98 3 a CELL EMAIL1YlP Pit, p.i P ® G / cep