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HomeMy WebLinkAboutBLDP-23-004208 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -=�., CITY YARMOUTH = MA DATE 1/30123 PERMIT# BLDP-23-004208 el f JOBSITE ADDRESS 83 OLD HYANNIS RD OWNER'S NAME DIWAN ANIL OWNER ADDRESS PATEL CHANDRIKA A 55 CEDAR MEADOWS DR TEATICKET,MA 02536-5882 TEL P TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES z 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 1 TOILET URINAL WASHING MACHINE CONNECTION 1 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❑ 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 (Michael Depascale LICENS13t2758 SIGNATURE MP JP 13CORPORATION ❑# I I PARTNERSHIP ❑# I I Lc ❑# I ❑ I ADDRESS 121 WORCESTER AVE APT D COMPANY NAME IMICHAEL DEPASCALE CITY IHUDSON STATE IMA I ZIP 1017493020 I TEL I FAX CELL I I EMAIL Imtd.plumbing@gmail.com S MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' C PO C-' MA DATE 3fAn ZL1 2013 PERMIT# ---- JOBS R SS Ca b►D I-1 y c.r.A t S ►roi iJ OWNER'S NAME CI r� r cv AN *Milk RE TEL y��-$33-2kK�LFAX riGoEEkR PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL y NEW: RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES O❑ FIXTURES 1 FLOOR-) BSM 1 2 3 4 5 6 7 8 _ 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN _ INTERCEPTOR(INTERIOR) , KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK 1 TOILET URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY m/ OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent p��vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 K1 a.,_PA. PLUMBER'S NAME LICENSE#3 2j5$ SIGNATURE MP 0 JP ail CORPORATION❑# PARTNERSHIP❑# LLC Cgit/1 IY 11 OSy COMPANY NAME NOD P 1 u Mb ^� ADDRESS -al C3 \j o = 4 )v CITY JC S°h ` J STATE N\ q-A ZIP On i(1 TEL 1 t1- 3" 2. t2.. FAX CELL EMAIL MT . Pi g 11i5 q; (3"r"v:,k. c.