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HomeMy WebLinkAboutBLDP-21-004085 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1. p MA DATE 1/25/21 PERMIT# BLDP-21-004085 r_ . CITY YARMOUTH l�`€ OWNERS NAME SABINA MICHAEL I TR JOBSITE ADDRESS 192 SOUTH SHORE DR UNIT 2 P OWNER ADDRESS THE M I SABINA&J M SABINA LVG TRUST 26 MISTY LN SOUTH YARMOUTH, TEL MA 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES NO FIXTURES -I 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN SHOWER STALL 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❑ 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. PLUMBERS NAME (waiter kenney I LICENSE 9202 SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# I COMPANY NAME I ADDRESS 23 summerwind lane CITY (north falmouth STATE IMA I ZIP 102556 I TEL I FAX I I CELL I I EMAIL 12/4 - aJ - �