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Home My WebLink AboutBLDP-22-006096 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ‘1/4r_4 41- CITY YARMOUTH MA DATE 4122/22 PERMIT# BLDP-22-006096 t'— JOBSITE ADDRESS 4 BUCKWOOD DR OWNER'S NAME Sarah Miller P OWNER ADDRESS 4 BUCKWOOD DR SOUTH YARMOUTH,MA 02664-1806 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL 0 PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES El NO El FIXTURFS • 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 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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 El OTHER TYPE OF INDEMNITY El BOND El 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 Mark Couto LICENSE 15856 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME MARK J COUTO ADDRESS 103 LAKE SHORE DR CITY BREWSTER STATE MA ZIP 026312429 TEL FAX CELL EMAIL markjcouto@yahoo.cam ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y f T -,m_ 5 . _ MA DATE' = �,� I »Gt.d I OJYE $ MAIv4Itl4 . ..__ ___y . - -_ '..�1.. 2 �"9- PERMIT# Z 4-. l •a JOBSITE DURESS E 4 'si.e,14-Lyra d D{ OWNER'S NAME SA MM.c lk..e", R DRESS TEL m _PIR 2 0 .i."::------ _�..._ .�__.��__�._ FAX \1 g t )E b t ANd Y TYPE COMMERCIAL ( EDUCATIONAL ' RESIDENTIA CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO , FIXTURES 1 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM . DEDICATED GRAY WATER SYSTEM . DEDICATED WATER RECYCLE SYSTEM - ✓ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK • LAVATORY ROOF DRAIN • SHOWER STALL SERVICE ! MOP SINK ` TOILET _ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY f 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 CHECK ONE ONLY: OWNER AGENT I 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 � lance with all Pertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME • Mark Couto LICENSE # 15856 SIGNATURE MP i JP CORPORATION'i # 3408 PARTNERSHIP # LLC # COMPANY NAME: Mark Couto Plb & Htg Inc_ ADDRESS 103 Lake Shore Dr CITY Brewster STATE MA ZIP 02631 . TEL 508-965-2145 , FAX 508-896-2577 CELL EMAIL Markjcouto@yahoo.com i