HomeMy WebLinkAboutBLDP-22-001001 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
, la CITY YARMOUTH MA DATE 8/23/21 PERMIT# BLDP-22-001001
JOBSITE ADDRESS 43 WEBSTER RD OWNER'S NAME 43 Webster Rd LLC
P OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURFS • FLOORS-. 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY 1 2
ROOF DRAIN
SHOWER STALL 1 1
SERVICE/MOP SINK
TOILET 1 2
URINAL
WASHING MACHINE CONNECTION 1
WATER HEATER 1
WATER PIPING 1
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❑ 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 Robert Maizaka LICENSE#0659 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ROBERT W MAIZAKA ADDRESS 3 CIRCLE CLOSE PO BOX 1092
CITY ORLEANS STATE MA ZIP 026531092 TEL
FAX CELL 7748365585 EMAIL bobmaizaka@comcast.net
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ ❑
FEES$ PERMIT#
PLAN REVIEW NOTES
Q0
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r:=1 CITY (6-Ai4-C/UYi1 MA DATE / 5.RC", & I PERMIT# • 2 Z— f (
Gae
JOBSITE ADDRESS 11 �
3 fi/2,5 �?�A OWNER'S NAME`5APIES
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[1
PRINT
CLEARLY NEW:[u ' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-0 Bsat 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1,
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM •
DEDICA I EU GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
LAVATORY _t, a _
ROOF DRAIN
SHOWER STALL 1-- 1-
SERVICE/MOP SINK
TOILET 1 a
URINAL
WASHING MACHINE CONNECTION
WATER HEA 1 ER ALL TYPES I
WATER PIPING 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 ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [0/ 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 aft of the details and information I have submitted or entered regarding this application are true and accurate to the t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliwith 'nest rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Gldi—(V- ✓/ ate ' ' LICENSE# I6659 SIG LIRE
MP[2 JP❑ CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME ,cIA L/, )4.24I 4 ADDRESS ,i-d
CITY c-''A t P/'JLIS STATE 1/C'- ZIP d 53 TEL
FAX CELL77 ` 36-SS$S EMAIL kozi J114 r 2/4 4-€ c rnC4.3tI. ,(✓Q~