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HomeMy WebLinkAboutBLDP-23-000416 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 7/26/22 PERMIT# BLDP-23-000416 JOBSITE ADDRESS 1175 ROUTE 28 OWNER'S NAME TOWN OF YARMOUTH P OWNER ADDRESS 1146 ROUTE 28 SOUTH YARMOUTH,MA 02664-4463 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL © RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El 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 1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN 1 FOOD DISPOSER FLOOR/AREA DRAIN 2 INTERCEPTOR(INTERIOR) 1 KITCHEN SINK 2 2 LAVATORY 2 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK 1 1 TOILET 2 2 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 1 1 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 Amanti I LICENS419 SIGNATURE MP El JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME IE.Amanti&Sons,Inc I ADDRESS 1390 Highland Ave CITY 'Salem I STATE IMA I ZIP 101970 I TEL 17813345487 FAX I 1 CELL I 1 EMAIL 1