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HomeMy WebLinkAboutBLDP-23-002461 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y�-_4� CITY YARMOUTH MA DATE 11/4/22 PERMIT# BLDP-23-002461 JOBSITE ADDRESS 1189 SILVER LEAF LN OWNER'S NAME POTVIN ROY D P OWNER ADDRESS POTVIN EILEEN T 21 BRATTLE ST WORCESTER,MA 01606 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES CI NO❑ FIXTURES Z 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 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 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. PLUMBERS NAME Rodrigo Franca LICENSE 34599 SIGNATURE MP 0 JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 30 wildwood CITY Yarmouth STATE MA 7 ZIP TEL FAX CELL EMAIL INFO@kmbplumbingand heating.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES$ PERMITS PLAN REVIEW NOTES L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i CITY_ •�t • YCk ark( .�t t MA DATE • PERMIT# - 0 3 , ITE ADIpRESS I �l. l� �[7� + OWNER'S NAME ern >l C) UUco-id L BuiLr c DE Rae'1"� RESS a*-L-1 TEL FAX TYP TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE --_ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ■�� DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN - INTERCEPTOR(INTERIOR) - KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL • SERVICE I MOP SINK TOILET URINAL - WASHING MACHINE CONNECTION ■■■ WATER HEATER ALL TYPES WATER PIPING TOTHER 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 D 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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. CCI4ti 60 1 A L�2,{in cc- PLUMBER'S NAME LICENSE# IA MP❑ JP tr CORPORATION❑# PARTNERSHIP 0#-1 LLC aft COMPANY NAME V,.CAY1 t i-0 ADDRESS l> LkJ 1 1�llui M.4 )h CITY Yc{ ik 6} STATE_ ! 1a ZIP c dG'-3 TEL cog - 3} -0fC I_� FAX CELL EMAIL t�N�'-': k-L4 Qtt 1 m I�t/J chv 4�.LCl4i !�j i'C71 �:,