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HomeMy WebLinkAboutBLDP-23-004426 k. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,�, _( CITY YARMOUTH MA DATE 2/9/23 PERMIT# BLDP 23 004426 !I JOBSITE ADDRESS 48 MONROE LN OWNERS NAME SAMATARO PAUL F Itfpa P OWNER ADDRESS ROBERTS WANDA B 48 MONROE LN WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES© NO❑ FIXTURFS z 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/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 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© NO 0 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 0 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 JOSH MACMICHAEL LICENSE W06114 SIGNATURE MP 0 JP 0 CORPORATION ❑# • PARTNERSHIP 0# LLC 0# COMPANY NAME CLEAR CHOICE HOME ADDRESS 8025 S WILLOW STREET UNIT 107 JMPROVFMFNTS CITY MANCHESTER STATE NH ZIP 031032311 TEL FAX CELL EMAIL L