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HomeMy WebLinkAboutBLDP-23-000209 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =�..N CITY YARMOUTH _ MA DATE 7113122 i PERMIT# BLDP-23-000209 I JOBSITE ADDRESS 33 BENTBLUFF LN OWNER'S NAME STANLEY JANE F P OWNER ADDRESS 33 BENT BLUFF LN YARMOUTH PORT,MA 02675-2513 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL Q PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES NO❑ 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 Alberto Gomez Alvarez LICENSE 11J007 SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Upper Cape Heating&Cooling ADDRESS PO Box 666 CITY Cataumet STATE MA ZIP 02534 TEL 5082749186 FAX CELL 7743926103 EMAIL 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