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HomeMy WebLinkAboutBLDP-23-004314 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/3/23 PERMIT# BLDP-23-004314 l l JOBSITE ADDRESS 42 RIVER ST OWNERS NAME MAllIE STEVEN A TR P OWNER ADDRESS MAZZIE FAMILY TRUST 129 BELL ROCK STREET EVERETT,MA 02149 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL E PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURES 1 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 _DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL 1 _SERVICE/MOP SINK _TOILET 1 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❑ NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m 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. PLUMBERS NAME (Fernando Coelho LICENSEIRIA I SIGNATURE MP © JP 0 CORPORATION ❑# I I PARTNERSHIP ❑# LLC ❑# I I COMPANY NAME IAII Cape hvac and plumbing I ADDRESS I16 wildwood Path CITY (WEST YARMOUTH I STATE IMA ZIP 1026730004 I TEL 15083645425 I FAX I 1 CELL I EMAIL I I