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HomeMy WebLinkAboutBLDP-22-001336 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 9/8/21 PERMIT# BLDP-22-001336 JOBSITE ADDRESS 25 CAMP ST OWNER'S NAME Ahmed Shahin P OWNER ADDRESS 25 CAMP ST WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES NO El FIXTURES • FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 1 WATER PIPING 1 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 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 Peter Riva LICENSE 13447 SIGNATURE MP © JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME PETER E RIVA ADDRESS 9 BAYVIEW ST CITY IMARSHFIELD I STATE MA ZIP 020502906 TEL I FAX ( I CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _1;g " CITY / 2 , �€ ; - ��O 1/Vt �=��� MA DATE � � PERMIT* > N fx^ I JOBSITE ADDRESS 2 ) C.�. vi S'* OWNER'S NAME L2� it ! 5 1 OWNER ADDRESS ,;,s t TEI '249% FAX 6` l 1.3 PEA OCCUPANCY TYPE I COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L 'R 1 T m l'' NEW:2' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NQ FIXTURES 11 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 GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN 7 , INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / WATER PIPING OTHER I ' 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 UABIUTY INSURANCE POLICY' 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT illr SIGNATURE OF OWNER OR AGENT L1.I I hereby certify that all of the details and information I have submitted or entered regarding this application a 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 i m ance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME pe-re c LICENSE# 4.5 ../ SIG MP 5 JP❑ CORPORATION 0# PARTNERSHIP❑.# LLGtE#5 3 LI COMPANY NAME 9/C/I ,c,d r.eJ3. [ ' ADDRESS Cr 41 t),i t,' S r CITY/'`/„ t0 / STATErr,. ZIP V % L) TEL 12 0-14" 5-i FAX / 3'' 120 CELL ` l EMAIL 6-c /—ZOt/1 (-1 1 44 C45644 C' :Z.' . A,(