HomeMy WebLinkAboutBLDP-23-001355 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
?_ % CITY 'YARMOUTH I MA DATE I9/14/22
�gi PERMIT# BLDP-23-001355
JOBSITE ADDRESS 18 SETUCKET RD I OWNER'S NAME IPONs ANNA R I
P OWNER ADDRESS 18 SETUCKET RD YARMOUTH PORT,MA 02675 I
ITEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑
PRINT RESIDENTIAL
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO 0
FIXTURES FLOORS--3 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
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
SERVICE/MOP SINK
TOILET
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 El NO El
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 Albert Cassano
LICENS 9A15 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# L_ PARTNERSHIP ❑#
C LLC []#
COMPANY NAME Cape Cod Mechanical Systems,Inc ADDRESS 8 Fruean Way
CITY South Yarmouth STATE MA
ZIP 02664 TEL 5083947501
FAX CELL ij EMAIL