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HomeMy WebLinkAboutBLDP-22-005326 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w„ E, CITY YARMOUTH MA DATE 3/23/22 PERMIT# BLDP-22-005326 JOBSITE ADDRESS 19 JACQUELINE CIR OWNER'S NAME KIMBALL MARK W P OWNER ADDRESS KIMBALL TIMOTHEA K 7 FERNWOOD DR EAST HAMPTON,CT 06424 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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/OIUSAND 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 1 SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION WATER HEATER 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❑ OTHER TYPE OF INDEMNITY❑ BOND 0 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 1i5496 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME BENJAMIN DIAMANTOPOULOS ADDRESS 25 ANTHONY RD CITY W YARMOUTH STATE MA ZIP 026733776 TEL FAX CELL EMAIL -R ,c F.L. d V Eli) CHUSE S UNIFORM APPLICATION FOR A ERMIT TO PERFORM PLUMBING WORK ,IT(� ' r!.`2 3 � �o� ., 6 MA DATE PERMIT# 22- rD 4, JOBSITE DRESS 0 NER'S NAME F> BUll.,pj[JG pEDARTME T ©y -Y --IIWIJEL_D ESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ca''''.-------- PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES NO FIXTURES 1 FLOOR-4 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/OILISAND 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 SERVICE/MOP SINK TOILET URINAL I — WASHING MACHINE CONNECTION WATER HEATER ALL TYPES j WATER PIPING �J - - - OTHER J INSURANCE COVERAGE: I have a current liability insurance policy or its sub ntial equivalent which meets the requirements of MGL Ch.142. YES Y NO 0 IF YOU CHECKED YES, PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ 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 Z. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t e 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 co fiance with all Pertinent provision of the Massachusetts State PI .'bing Cod and Chapter 1 of the Ge ral Laws. Ar n tg14 PLUMBER'S NAME //cif/ s LICENSE#/5�� SIGNATURE MP IcEr*--- 111 CORPO'ATIONJI# PARTNERSHIP❑.# LLC # COMPANY N �E ADDRESS A ttO/ V Ai CITY r l V 7T— STATE ail.ZIP TEL ___}.... FAX CELL 8.3031G EMAIL V OS • I' ` - G