HomeMy WebLinkAboutBLDP-23-000923 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
q- � CITY YARMOUTH MA DATE 8/22/22 PERMIT# BLDP-23-000923
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JOBSITE ADDRESS 1 SEASIDE VILLAGE RD OWNER'S NAME IMELARAGNI DAVID C
P OWNER ADDRESS 2 DIANA DR WOBURN,MA 01801 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL
El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ 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 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
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 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 'Kevin Decoteau LICENSE116532 I
SIGNATURE
MP El JP El CORPORATION ❑# I I PARTNERSHIP ❑# I I LLC ❑# I
COMPANY NAME I I ADDRESS 138 Powhatan Rd
CITY !South Yarmouth I STATE IMA I ZIP 102664 I I
TEL
FAX 1 I CELL I I EMAIL I