HomeMy WebLinkAboutBLDP-22-005384 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 3/25/22 PERMIT# BLDP-22-005384
JOBSITE ADDRESS 109 SEAVIEW AVE UNIT 3 OWNER'S NAME ROGALSKI WAYNE
P OWNER ADDRESS ROGALSKI TRACY A 1 RITA DR BETHEL,CT 06801-3026 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ 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 1
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING 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 Benjamin Diamantopoulos LICENSE 1b496 SIGNATURE
MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME BENJAMIN DIAMANTOPOULOS ADDRESS 25 ANTHONY RD
CITY W YARMOUTH STATE MA ZIP 026733776 TEL
FAX CELL EMAIL
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•
-�__ CITY �.,° I I'C_,. 0 } -1 7
=i_ - `. 1' 1 MA DATE `'� 22 PERMIT# t - 5-3 2'1
f , _
JOBSITE ADDRESS 70 tr i ai �"r O NER'S NAME rl
POWNER ADDRESS ,`j / TEL 6� ti7q 3%
TYPE OR OCCUPANCY TYPE COMMERCI EDUC IONAL '"
PRINT 0 RESIDENTIAL[�
CLEARLY NEW:❑ RENOVATION:Lam' REPLACEMENT:' PLANS SUBMITTED: YES 0 NO al------
FIXTURES 1 FLOOR-i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 4
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN r—�
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY °$
ROOF DRAIN
'
SHOWER STALL
SERVICE/MOP SINK g
TOILET
1 =URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER '9 -.�
-
INSURANCE COVERAGE: �r�
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 OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
1` CHECK ONE ONLY: OWNER
SIGNATURE OF OWNER OR AGENT ❑ AGENT El
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 comp' nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. g
56
PLUMBER'S NAME " ) / .4..,....-MP JP ! �Y�,-� SIGNATURE
CORPORATION # PARTNERSHIP❑.# LLC❑#
COMPANY N E i / f``'r
ADDRESS 2 �` C)
CITY
STATE A- ZIP 41r C .
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FAX CELL � � ‘/����MAI
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