HomeMy WebLinkAboutBLDP-22-004178 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r CITY YARMOUTH MA DATE 1/26/22 PERMIT BLDP-22-004178
�fi_ JOBSITE ADDRESS 136 KATES PATH VILLAGE OWNER'S NAME Christine Young
P OWNER ADDRESS 136 KATES PATH YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑
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
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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY 0 BOND❑
OWNERS 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 16496 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# J PARTNERSHIP ❑# LLC ❑#
COMPANY NAME BENJAMIN DIAMANTOPOULOS ADDRESS 25 ANTHONY RD
CITY W YARMOUTH STATE MA ZIP 026733776 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT TO PERFORM PLUMBING WORK
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J �� BITE ADDRESS -7- ` a4r4--
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0 R ADDRESS :5 TEL4 f 7 ,Ve V_5 i(
_'', :_TY CY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB - '
CROSS CONNECTION DEVICE -
DEDICATED SPECIAL WASTE SYSTEM ,
DEDICATED GASIOIUSAND SYSTEM T
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 V
SERVICE I MOP SINK •
TOILET
URINAL
. WASHING MACHINE CONNECTION "
WATER HEATER ALL TYPES
WATER PIPING
OTHER
SURANCE COVERAGE:
{ I have a current liability insurance policy or its su ntial equivalent which meets the requirements of MGL Ch.142. YES IIIZNO 0
IF YOU CHECKED YES, PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
L-I I hereby certify that all of the details and information I have submitted or entered regarding this application are true a accuiate to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compli c with all Pertinent provision of the
Massachusetts State Plu bing Code and Chapter 142 of the General Laws. /�i
PLUMBER'S EP LICENSE# 1 ��'�/
SIGNATURE
MP JP CORPO TION 0# PARTN SHIP LLC #
COMPANY N E 766/7/1:1- PillADDRESS .� riAtr/feiVki‘--2:)
CITY /W4 STATE da ZIP 3T A�� /
FAX CELL EMAI /1 / U Q v
•
•
q ;
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES