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HomeMy WebLinkAboutBLDP-21-003368 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —Mia CITY YARMOUTH 1 MA DATE 12/14/20 PERMIT# BLDP-21-003368 l JOBSITE ADDRESS 51 LUMBERJACK TRAIL OWNERS NAME BARNARD DONALD A P OWNER ADDRESS BARNARD NANCY J 195 SHEFFIELD AVE LONGMEADOW,MA 01106-3230 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:© RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 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) _ r. KITCHEN SINK LAVATORY 3 2 ROOF DRAIN SHOWER STALL 1 1 SERVICE/MOP SINK TOILET 2 1 URINAL WASHING MACHINE CONNECTION 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 G°✓ a I 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 at plumbing work and installations performed under the permit issued for this application will be in compliance with at Pertinent provision al the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Fernando Coelho LICENSE 34508 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 16 Wildwood Path CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL fernando252c@gmail.com l&A;D