HomeMy WebLinkAboutBLDP-19-000141 y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 7/9/18 PERMIT# BLDP-19-000141
JOBSITE ADDRESS 29 LAKEWOOD RD OWNER'S NAME CARDONE THOMAS A
P OWNER ADDRESS CARDONE DENISE M 86 WHITTAM AVENUE SPRINGFIELD, MA TEL
01118
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL CI
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YESD NO El
FIXTURFS • 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
ROOF DRAIN
SHOWER STALL _
SERVICE/MOP SINK _
TOILET _
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER 1 _
WATER PIPING
OTHER I
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES El 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❑ 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 dmitri chalke LICENSE 3727 I SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# 3727 PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS POB 304-1378 Main St
CITY East Dennis STATE MA ZIP 02641 TEL
FAX CELL 5082948361 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVE AS THE ❑ CI
DFDRAIT
FEES$ PERMIT#
PLAN REVIEW NOTES