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HomeMy WebLinkAboutBLDP-23-005884 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • CITY YARMOUTH MA DATE 4/24/23 PERMIT# BLDP-23-005884 V1'I j JOBSITE ADDRESS 72 SEAVIEW AVE OWNER'S NAME ARNOLD SCOTT P OWNER ADDRESS ARNOLD GRETCHEN 47 RIMFIELD DRIVE SOUTH WINDSOR,CT 06074 • TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES FLOORS—> BSI/11 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 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 ❑ 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 Dimosthenis Kapoukranidis LICENSE 314414 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 9 Adams Road CITY West Yarmouth STATE MA ZIP 026732401 TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK k._1�t") CITY \iafn,aE.)�-j'1 MA DATE Ott/2c// l PERMIT# • I 23"OU � . JOBSITE ADDRESS 7 2 5ratr i etc-) ,/-I V OWNER'S NAME S co-14- 4Y h0 Id P OWNER ADDRESS 4712r01.09/pi. 5.i,B,rdSo,r G;r0 607ra TEL I'60 2G0--2113Q FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL( , PRINT CLEARLY NEW:❑ RENOVATION:(" REPLACEMENT:0 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER f DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY ROOF DRAIN SHOWER STALL / SERVICE/MOP SINK TOILET I rR F C E I ,_ ._ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - A�� -1 WATER PIPING OTHER -- BUILD NG DIPAR'MEN` oY - , I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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 CHECK ONE ONLY: OWNER 0 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 complian ' wit all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ r1>'YjoS117€vIis k$trooKrcavil4i} LICENSE# "3L 4I 1 / SIGNATURE MP❑ JP 0 CORPORATION 0# PARTNERSHIP❑# LLC❑# COMPANY NAME 'i VI'10 S"4lj eri is k(42,0 CS- ADDRESS 61 4 J ckkA-fS 0,4 CITY y,, ,,,,,,„{h STATE tit ZIP 02.e13 TEL FAX CELL X00C) (ty j ''/63 EMAIL 10oOkyuli c? ho1-''rrc 1 I<<o