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HomeMy WebLinkAboutBLDP-22-000473 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK g, CITY YARMOUTH MA DATE 7/26/21 PERMIT# BLDP-22-000473 t' JOBSITE ADDRESS 75 RITA AVE OWNER'S NAME PERONE ANTHONY S P OWNER ADDRESS PERONE MILDRED 75 RITA AVE SOUTH YARMOUTH,MA 02664-1979 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO❑ FIXTURES • FLOORS--* 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/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 OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO Cl IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El BOND El 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 Joseph Madden LICENSE 3k1558 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME I ADDRESS 15 Perrys Way CITY (Harwich I STATE MA ZIP 02645 TEL 17747223545 FAX I I CELL 7747223545 EMAIL