HomeMy WebLinkAboutBLDP-23-004031 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-� CITY YARMOUTH MA DATE 1/23/23 PERMIT# BLDP-23-004031
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a JOBSITE ADDRESS 22 NIMBLE HILL DR OWNER'S NAME RESIDENT
P OWNER ADDRESS ICARNES KAREN E 22 NIMBLE HILL DR YARMOUTH PORT,MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YESD NO El
FIXTURES a 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 2
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK _
TOILET _ 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
LIABILITY INSURANCE POLICY 0 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 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 Kenneth Duarte LICENSE 111012 SIGNATURE
MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP Do LLC Do
COMPANY NAME ADDRESS 37 collins ave
CITY Centerville STATE MA ZIP 026322345 TEL
FAX CELL
EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑ CI
FEES$ PERMIT#
PLAN REVIEW NOTES