HomeMy WebLinkAboutBLDP-22-002434 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 10/28/21 PERMIT# BLDP-22-002434
JOBSITE ADDRESS 84 HOMERS DOCK RD OWNER'S NAME Alberto Maitino
P OWNER ADDRESS 84 HOMERS DOCK RD YARMOUTH PORT,MA 02675 TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTS:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOORS—s 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 2
ROOF DRAIN
SHOWER STALL 2
SERVICE/MOP SINK
TOILET 2
URINAL
WASHING MACHINE CONNECTION 1
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❑ 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 at Pertinent provision
of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Nhan Nguyen LICENSE 1b210 SIGNATURE
MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME NHAN H NGUYEN ADDRESS 284 Bridge St
CITY Raynham STATE MA ZIP 027671975 TEL
FAX CELL EMAIL hightek2010@yahoo.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No J 22
THIS APPLICATION SERVE AS THE El Elk` G L X
FEES$ PERMIT#
PLAN REVIEW NOTES
1 %
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
R --�= ' V g V 11A r t _ ICI MA DATE 1 c 1 2 gl Z / PERMIT# L L - Z`+ 3`f
DC 8 2021
O�JOBOITE ADDRESS "84 l+c5 Y\4 E f2 )O�I� RD OWNER'S NAME
VOWNER ADDRESS TEL a, I 4 S `hJ -766 f-FAX
B ILDING DEPARTMENT
By: _TYPE OR.___OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL p,
PRINT
CLEARLY NEW:( RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR-4 eSM 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 SYSTEM -
DISHWASHER
DRINKING FOUNTAIN -
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
I LAVATORY Z •
ROOF DRAIN
SHOWER STALL
I SERVICE I MOP SINK
TOILET '2_
URINAL
WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES -
WATER PIPING
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
LIABIUTY 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# p 'i 10 . SIGNAT RE
MP 171 JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME H 1 - H 16-IL > -Jr r--1 ADDRESS 2-8 L/ 3 jZ I OLt
CITY -F\y(- H STATE Ted I.\ ZIP l-T C TEL C t d •Z V-nn2193
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