HomeMy WebLinkAboutBLDP-20-005573 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 4/27/20 PERMIT# BLDP-20-005573
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JOBSITE ADDRESS 123 RUN POND RD OWNER'S NAME LUONGO FRANCESCO
OWNER ADDRESS LUONGO AN&P M 135 WEST ST ATTLEBORO,MA 02703-2631 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m
PRINT
CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO
FIXTURES i 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/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
WATER HEATER
WATER PIPING 1
OTHER 1
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❑
OWNERS 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.
LICENS41i276 SIGNATURE
PLUMBER'S NAME ISHAUN KELLY I
MP 13 JP ❑
CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I
120 carol rd
COMPANY NAME Ikelly plumbing&heating I ADDRESS
I CITY STATE IMA I ZIP 102048 I TEL I
(Mansfield
FAX
CELL 7742594873 EMAIL I