HomeMy WebLinkAboutBLDP-23-004610 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
11/4
ii CITY YARMOUTH MA DATE 2/21/23 PERMIT# BLDP-23-004610
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-----11— JOBSITE ADDRESS 73 HAZELMOOR RD_, OWNER'S NAME BBENOIT JAMES F
P OWNER ADDRESS BENOIT ALLISON J 2 PHEASANT TRAIL HUDSON,MA 01749 TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0
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CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO 0
FIXTURES z FLOORS-0 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 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
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 0 NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 (Kenneth Duarte I LICENSEIVA I
SIGNATURE
MP 0 JP 0 CORPORATION ❑# I I PARTNERSHIP ❑# I , LLC ❑# I I
COMPANY NAME I I ADDRESS 137 Collins ave
CITY (Centerville I
STATE IMA I ZIP 1026322345 I TEL I
FAX I I CELL I I EMAIL