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HomeMy WebLinkAboutBLDP-23-004408 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK q CITY YARMOUTH MA DATE 2/9/23 PERMIT# BLDP-23-004408 JOBSITE ADDRESS 464 ROUTE 28 OWNER'S NAME S&C REALTY INVESTMENT CO LLC P OWNER ADDRESS 169 MAIN ST STONEHAM,MA 02180 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN 6 INTERCEPTOR(INTERIOR) KITCHEN SINK 2 LAVATORY 2 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 2 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 BRIAN COUTO LICENSE 1;6316 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME BRIAN K COUTO ADDRESS 42 OAK ST APT 1 CITY FALL RIVER STATE IMA ZIP 027204913 TEL FAX CELL EMAIL briancoto@ymail.com - .........__MA,S ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYr y__ . ``"^€'�-��^ MA DATE 2. 7 2 PERMIT# L 3 if`(e' i5 0 ?.1 ITEADDRESS ' 41r.4 ? n OWNER'S NAME " >,-. { .I2) i_._ yy BUIPrNG C)LrR DRESS TEL BY FAX TYPIW—OCCDPATICY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ 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 ______r____- DEDICATED GREASE SYSTEM 1 - ___________ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) I KITCHEN SINK - LAVATORY ,a _ ROOF DRAIN SHOWER STALL . SERVICE/MOP SINK TOILET URINAL . WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER - I have a current liability insurance policy or its substantial equivalent INSURANCE which meets the requirements of MGL Ch.142. YES - © NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0- 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. � CHECK ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT ❑ AGENT ❑ �I 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 d,,, ti cl,. z LICENSE# /.- %l. SIGNATURE MP❑ JP❑ CORPORATION 0# PARTNERSHIP .# LLC # COMPANY NAME /� , C ❑ _ ADDRESS Z — v CITY Q._, JC STATE °. ZIP `o Z72'-z-) TEL FAX CELL` ci_tc-t3 -'-'s Zeee) EMAIL