HomeMy WebLinkAboutBLDP-20-003719 1431 <9411 / OVT 1,e0
• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 1/6/20 PERMIT# BLDP-20-003719
JOBSITE ADDRESS 67 CAPT WRIGHT RD OWNER'S NAME LEMIRE GEORGE R LIFE EST
P OWNER ADDRESS LEMIRE ELEANOR M LIFE EST 67 CAPTAIN WRIGHT RD SOUTH YARMOUTH, MA -EL
02664-2859
TYPE OR OCCUPANCY TYPE COMMERCIAL n RESIDENTIAL n
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CLEARLY NEW:[] RENOVATION:[] REPLACEMENT:[] PLANS SUBMITTED: YES[] NOn
FIXTURES: 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 1
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR (INTERIOR) -
KITCHEN SINK 1
LAVATORY 4
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 2 _
URINAL _
WASHING MACHINE CONNECTION 1
WATER HEATER 1 ,
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. YESM NO n
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 Kenneth Duarte LICENSE10012 SIGNATURE
MP n JP [] CORPORATION I 1# PARTNERSHIP nr LLC
COMPANY NAME Kenneth J Duarte ADDRESS 37 COLLINS AVE
CITY CENTERVILLE STATE MA ZIP 026322435 TEL
FAX CELL EMAIL
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