HomeMy WebLinkAboutBLDP-23-11802 N'1 1 -._
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
n _fi
-trim CITY Yarmouth I MA DATE i10/24/2023 J
�- u PERMIT# 13LI) 23 1/5 )2-
ma
JOBSITE ADDRESS 6 Merrymount Road I OWNER'S NAME James Igoe J
POWNER ADDRESS ! TELr617-921-0433 FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL'J EDUCATIONAL .__I RESIDENTIAL -
PRINT
CLEARLY NEW: - RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES F] Nor]
FIXTURES-1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r 1
CROSS CONNECTION DEVICE 1
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM — i
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM 1, - .
DISHWASHER ,�1
DRINKING FOUNTAIN
FOOD DISPOSER
^FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) 4'
KITCHEN SINK 1 '
LAVATORY 1 2
ROOF DRAIN
SHOWER STALL 1 1
SERVICE/MOP SINK H
TOILET 1 2
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER ALL TYPES 1
WATER PIPING 1 1
OTHER ~�
- --
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES . NO U
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.
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 complian with ertinen rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �%«. —
PLUMBER'S NAME Robert W Maizaka —3 LICENSE# .10659 —6 SIG TURF
MP - JP j CORPORATION # `PARTNERSHIP# LLCLI#F •
COMPANY NAME Robert W Maizaka ADDRESS PO Box 1092
---pFC � V � D
TE
CITY Orleans .1 STATE MA ZIP 02653 I TEL 774-8 ---- ___I
FAX CELL EMAIL bobmaizaka@comcast,net nrr 2 4, 2023 i
1 BUILDING DEPARTMENT
By _
L --