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Home My WebLink AboutBLDP-23-000248 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK M, et CITY IYARMOUTH I MA DATE I7/14/22 I PERMIT# BLDP-23-000248 JOBSITE ADDRESS 129 KATHARYN MICHAEL RD UNIT4 OWNER'S NAME(Margaret Carvalho D OWNER ADDRESS 129 KATHARYN MICHAEL ROAD YARMOUTH PORT,MA 02675 I TEL I r TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 WATER HEATER 1 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❑ 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❑ 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. PLUMBERS NAME (Brian Clark I LICENS418164 I SIGNATURE MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# u LLC ❑# COMPANY NAME IBRIAN K CLARK I ADDRESS PO BOX 2288 CITY ORLEANS STATE MA ZIP 026536288 TEL FAX CELL EMAIL cbplumbing13@gmail.com • SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • 1 F CITY a. i I 64160.4MA DATE -1 Z-5 2'`1 —Z� PERMIT# ,� R ii tt j VIE 'DI RESS Lc( l<c ,c /ryn i Gke4 ER'S NAME OWNEft ,P I,. SS trial LDI NGD%PART TEL FAX no y P • : '` "-"':-• ' PE COMMERCIAL INT ❑ EDUCATIONAL ❑ RESIDENTIAL[G� CLEARLY NEW:0 RENOVATION: PLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0 FIXTURES 7 FLOOR—+ BSM 1 2 3 4 5 6 7 8, 9 BATHTUB 10 11 12 13 14 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 LAVATORY • ROOF DRAIN _ SHOWER STALL _ SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION i/ WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY l OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the l' Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT El LI 1 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 edge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe 'vent r 'si g Massachusetts State Plumbing Code and Chapter 142 of the General Laws. the PLUMBER'S NAME LICENSE# /3/67. SIGNATURE MP ,1P❑ CORPORATION 0# PARTNERSHIP # "B�\ um bi n 4- ❑ LLC❑# COMPANY NAME C / Cp� ADDRESS d 22 CITY O"' 4.(2iv vY I5 STATE ZIP C_re. C TEL FAX CELL 57.5 '-aC/-7 /9f EMAIL L‘4D t