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HomeMy WebLinkAboutBLDP-23-004936 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 3/8/23 PERMIT# BLDP-23-004936 JOBSITE ADDRESS 547 ROUTE 28 OWNER'S NAME INIKODEMOS PAUL TRS P OWNER ADDRESS NIKODEMOS FAMILY TRUST 84 HIGH STREET WILMINGTON 01887-3010 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES NO m FIXTURES z 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ 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 Benjamin Diamantopoulos LICENSE 16496 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME BENJAMIN DIAMANTOPOULOS ADDRESS 25 ANTHONY RD 25 ANTHONY RD CITY IW YARMOUTH STATE MA ZIP 026733776 TEL FAX CELL I EMAIL bendiamantopoulos@gmail.com • MASSAC 4-ji- , pL z HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 27 '' V. � 4 O1/7- J�'� ( / MA DATE �DP,Z3"OQy9 PE MIT# MAR 06 202 'B`'rE P°DRESS f/V 6'7.- O TEOWNERL 'S NAME �J ij(,, MEE N R B ILD'Pl6 DEPARTMENT ADDRESS FAX ) B - _OCCUPAnICY TYPE COMMERCIAL[9-"'--------- EDUCATIONAL PRINT ❑ RESIDENTIAL CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:[y� PLANS SUBMITTED: YES 0 NO❑ FIXTURES 7. FLOOR-+ 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 SYSTEM ' DISHWASHER " DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN - INTERCEPTOR(INTERIOR) KITCHEN SINK — LAVATORY _ ROOF DRAIN SHOWER STALL - l SERVICE I MOP SINK L TOILET j URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER (.._0 tP 3 I/11g- I INSURANCE COVERAGE: 1 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 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. • CHECK ONE ONLY: OWNER 0 AGENT 0 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 corn ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER' AME r- L ,. LICENSE#/c SIGNATURE MP J �y � CORPORATION❑# PARTNERSHIP❑.# LLC 0# COMPANY NAME / O /1 f (^ PØl ADDRESS HatJt7 /e4 _ CITY yri 1 giv STATE A6 ZIP (26 7 5 TEL5C636O39 FAX CELL EMAILPGGO-Id)aina►v2)73,0CJI0_` 6 e QGT/gl f