HomeMy WebLinkAboutBLDP-20-005432 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r: CITY YARMOUTH MA DATE 4/9/20 PERMIT# BLDP-20-005432
JOBSITE ADDRESS 28 GREENLAND CIR OWNER'S NAME DICARLO JOSEPH
P OWNER ADDRESS DICARLO MARY A 202 PAKACHOAG ST AUBURN,MA 01501 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL E RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES NO El
FIXTURES _l 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 1
LAVATORY 1
.�
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION ..
WATER HEATER C�
WATER PIPING 1
OTHER 1
OTHER DESCRIPTION:
INSURANCE COVERAGE: +
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 111 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 Anson Celin LICENSE 32655 SIGNATURE
MP El JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ANSON CELIN ADDRESS 68 SUFFOLK AVE
CITY WEST YARMOUTH STATE MA a ZIP 026731444 TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE PERMIT El
1411-- PLO `' FEES$ PERMIT#
t i /I/; PLAN REVIEW NOTES
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