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Home My WebLink AboutBLDP-23-004424 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �, CITY YARMOUTH MA DATE 2/9/23 PERMIT# BLDP-23-004424 l'-- JOBSITE ADDRESS 51 LILY POND DR OWNER'S NAME Paul Tierny P OWNER ADDRESS 51 LILY POND DR SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ 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 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION 1 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 0 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 Gaige Depina LICENSE*1886 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 61 Carter CITY Brockton STATE MA ZIP 02302 TEL FAX CELL 'T)1/ ,g17 / 1 e-S-- EMAIL GAIGE.DEPINA11796@GMAIL.COM Yar riou-l-`l BLD P-2."3-OO9 Z >7 +-- i,_ ACHUSETTS UNIFORM APPUCATION FORA PERMIT TO PERFORM PLUMBING WORK 1_ l r '� ..�. ' MA DATE—G PERMIT# - • [0 81�,23-E ' D SS IS I 11 I`' p (; (d\ OWNER'S NAME-RAJ1 ►e Y BUI P: NGDErAWN .-•,,,II• SS (4t ruUl t .C\ $ y1�S TEL 6 17 ((al q 7 FAX BY: ----- Or n(y. / r as l.s q TYPE OR OC I•' , 'TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL r PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES Q/NO❑ FIXTURES 1 FLOOR-I 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 SYSTEM DISHWASHER . DRINKING FOUNTAIN _ FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _ 1 — LAVATORY 1 ROOF DRAIN SHOWER STALL T ' , SERVICE/MOP SINK I TOILET I j URINAL " . WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING J OTHER II INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 0 OTHER TYPE OF INDEMNITY 0 BOND 0 A OWNER'S l NCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the j Masspetii Gene 'aws,and that my signature on this permit application waives this requirement. - = v / CHECK ONE ONLY: OWNER 0 AGENT 4'E 0. e' R OR AGENT T L 1 I hereby certify that all of the de ails and nformation I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and stalls,Ins performed under the permit issued for this application will be in corn 'ante with all Pertinent ro ' io of the 9 Massachusetts State Plumbing •od: and Chapter 142 of the General Laws. Sge k. PLUMBER'S NAME 0..‘sz, D n 0, LICENSE#�� IGNATURE MP❑ JP ErCORPORATION 0# PARTNERSHIP # LLC 0# COMPANY NAME ADDRESS 47 L ar <-) CITY. j fa k 1h K STATE/1a s ZIP OZ 30-z, TEL / Vs 2 q 7'l 7 V5 FAX CELL 2 7/2- 617 'lc/0 EMAIL aA t I(G1 I J 7 q6 e5n) t