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HomeMy WebLinkAboutBLDP-23-001156 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK III,/ CITY YARMOUTH MA DATE 9/1/22 PERMIT# BLDP23-001156 JOBSITE ADDRESS 398 LONG POND DR OWNERS NAME MARTONE BARBARA R TR P OWNER ADDRESS MARTONE REALTY TRUST II 16 GRANDVIEW AVENUE WAKEFIELD,MA TEL 01880-3657 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES NO m 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/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 1 ROOF DRAIN SHOWER STALL 1 1 SERVICE/MOP SINK TOILET 1 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© NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m 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 Justin Hogg LICENSE 3R412 SIGNATURE MP ❑ JP El CORPORATION ❑# PARTNERSHIP El# LLC ❑# COMPANY NAME Justin Hogg Plumbing&Heating Inc. ADDRESS 63 swift brook rd CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 15082373694 I FAX I I CELL I I EMAIL I I