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HomeMy WebLinkAboutBLDP-23-002558 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 'r M, CITY YARMOUTH MA DATE 11/8/22 PERMIT# BLDP-23-002558 1i ;' JOBSITE ADDRESS 71 OLD HYANNIS RD OWNER'S NAME EZZAOUI ABDELAAZIZ P OWNER ADDRESS 71 OLD HYANNIS RD YARMOUTH PORT,MA 02675-1767 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0 FIXTURES 1 , FLOORS-4 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 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. PLUMBER'S NAME thomas queally LICENSE 33582 SIGNATURE MP ❑ JP © CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME THOMAS V QUEALLY ADDRESS 105 Plain St CITY Pembroke STATE MA ZIP 023593230 TEL FAX CELL EMAIL Isurfsupplumbing@gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =1€ e CITY yorivocii-fri uu MA DATE 1 / 2?� PERMIT# '- JOBSITE ADDRESS 10Z I b (! 1 4 YI Y?1s 1y0 OWNERS NAME IV))IC'Cr!L/ POWNER ADDRESS 0 Dorcor " b TEL FAX TYPE OR OCCUPANCY PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIA PRINT CLEARLY NE . RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El FIXTURES 7 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 GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER '— FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY / ROOF DRAIN _ SHOWER STALL I' R E C E I V E SERVICE/MOP SINK —Z , TOILET Iau URINAL - NOV0 3 GULL . j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 BUILDIk4G DEPARTMENT WATER PIPING B': OTHER - - 1 RANCE COVERAGE: I have a current liability insurance policy or its subst 'al equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0 i 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT ,� I hereby certify that all of the details and infolmation I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installs' s performed under the permit issued for this application will be in complia ce w h all nt prov ' V Massachusetts State Plumbing C and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# '� SIGNATURE MP❑ JP CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME ThaitS QtiroCGI jd--- C ADDRESS 9 b., 00h CI-"C CITY /403'1c0h STATEYY3 ZIP 02 34/I TEL FAX CELL 7D 73 1) EMAIL `7orl-5uppLoiY/bil'lygcfrj„q/L • Ca Sh - 70