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HomeMy WebLinkAboutBLDP-20-004021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH —1MA DATE 1/22/20 PERMIT# BLDP-20-004021 JOBSITE ADDRESS 74 HATCH RD OWNER'S NAME SMITH CHARLANN M P OWNER ADDRESS C/O CHARLES ZECCHIN TRS 188 GLENDALE AVE WINSTED,CT 06098 -EL TYPE OR OCCUPANCY TYPE COMMERCIAL n RESIDENTIAL n PRINT CLEARLY NEW:n RENOVATION:n REPLACEMENT:n PLANS SUBMITTED: YES] NOn 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) 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] NOR-1 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. PLUMBER'S NAME Leon Clark LICENSEM734 SIGNATURE MP fl JP ] CORPORATION I PARTNERSHIP r LLC ft COMPANY NAME LEON E CLARK ADDRESS 16 PLASHES DR CITY DENNIS PORT STATE MA ZIP 026391505 TEL FAX CELL EMAIL v