HomeMy WebLinkAboutBLDP-23-003168 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Z,y,=�s CITY YYARMOUTH MA DATE I12/8/22 I PERMIT# BLDP-23-003168
JOBSITE ADDRESS I553 ROUTE 28
OWNER'S NAME ISHRIM INC
P OWNER ADDRESS C/O D/B/A HUNTERS GREEN MOTEL 553 ROUTE 28 WEST YARMOUTH,MA
02673
TYPE OR OCCUPANCYI TEL
TYPE COMMERCIAL ❑ RESIDENTIAL ❑PRINT
CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES El NO El 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
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
OTHER 1
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 Alex Braga I
LICENSIItassachusetts SIGNATURE
MP ❑ JP 0 CORPORATION ❑# I PARTNERSHIP ❑#
LLC ❑# I I
COMPANY NAME Braga Brothers Inc ADDRESS 110 breeds hill road Unit#5
CITY Hyannis STATE MA
ZIP 026011864 TEL 5088274260
FAX CELL
EMAIL