HomeMy WebLinkAboutBLDP-22-004429 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,, el CITY YARMOUTH MA DATE 2/9/22 PERMIT# BLDP-22-004429
4 JOBSITE ADDRESS 21 ROBERTA DR OWNERS NAME LANCIANO MICHAEL S
P OWNER ADDRESS LANCIANO KATHARINE J 21 ROBERTA DR WEST YARMOUTH,MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m
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CLEARLY NEW: m RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO m
FIXTURES • 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/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 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
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❑ NO ❑
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 Craig Bishop LICENSE 1b101 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME High Efficiency LLC ADDRESS 378 MA-130
CITY Sandwich STATE MA ZIP 02563 TEL 5088253695
FAX CELL EMAIL