HomeMy WebLinkAboutBLDP-23-001331 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 9/13/22 PERMIT# BLDP-23-001331
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I r JOBSITE ADDRESS 16 DANBURY ST OWNER'S NAME FEMINO SANDRA L
P OWNER ADDRESS 4320 HEATH LAND LN LAKE WALES,FL 33859 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
FIXTURES • 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 1
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 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 0
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 f5496 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME BENJAMIN DIAMANTOPOULOS ADDRESS 25 ANTHONY RD 25 ANTHONY RD
CITY IW YARMOUTH I STATE MA ZIP 026733776 TEL
FAX I I CELL I I EMAIL bendiamantopoulos@gmail.com
} RECEIVED
MAP:
PfiRe ; 2zEc0MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORItiV, ,-
oWORKMENT
MA DATE PERMIT#2 3' /3 3/
1I - CITY ,_... .y - r
JOBSITE ADDRESS [ tio ,7/d'N6 /eY R`S AME[ i
j OWNER ADDRESS ' ,P ' e TELJ 'FAX I
TYPE OR OCCUPANCY COMMERCIAL EDUCATI 0 RESIDENTIAL
PRINT PLANS SUBMITTED: YES❑ NO
CLEARLY NEW: RENOVATION: REPLACEMENT:
FIXTURES'1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
•I ���
CROSS CONNECTION DEVICE ,
DEDICATED SPECIAL.WASTE SYSTEM 011110,
DEDICATED GAS/OIL/SAND SYSTEM '
DEDICATEDQDEDICATEDGREAREASEE SYSTEM lialiVan
DEDICATED GRAY WATER SYSTEM
TDEDICATED WATER RECYCLE SYSTEM
DISHWASHER
_DRINKING FOUNTAIN
FOXED DISPOSER OINK 110101 NW Nti- M. N I•NO 1111101 an SIMI N OM N'
FLOOR/AREA DRAIN - .1111Ilia..
-
INTERCEPTORINTERIOR nonrt OM III NM MIKITCHEN SINK OINK IIIIIIIII
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LAVATORYMINI
ROOF DRAIN
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SHOWER STALL .
SERVICE!MOP SINK
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TO
ILET
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URINAL 1 .. . Ili�' `
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WASHING MACHINE CONNECTION !�!r� `
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WATER HEATER ALL TYPES
WATER PIPING
nonsingligni-d•-•-•
OTHER 1111111iiii iM.NM...
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INSURANCE COVERAGE: `
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES id NO [J.
IF YOU CHECKED YES,PLEASE INDICATE THE F 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 thia permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the decals and information I have submitted or entered regarding this application are tru and accurate to the best of my knowledge
and that all plumbing work and installatkms performed under the permit issued for this ajpiication will be in corn ante with all Pertinent provision of the l
MassachusettsState Plumbing Code and Chapter 142 of the General taws.
PLUMBER'S NAME 0 SIGNATURE
MP Er.; CORPORATION IPARTNERSHIPU#1 1 LLCD#1 1
COMPANY NAMEVkey9R1-- ADDRESS[ ,'�j/ `. I
CITY[ jt7 1f-1 ' ZIP TEL all l►!!!,r AffriAllLIC�
STATE
FAX 1 1 CELL 1 EMAIL ii