HomeMy WebLinkAboutBLDP-17-005034 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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1 CITY YARMOUTH MA DATE 3/31/17 PERMIT# BLDP-17-005034
T�k , JOBSITE ADDRESS 59 STRATFORD LN OWNER'S NAME NIGOGHOSIAN JACK
P OWNER ADDRESS NIGOGHOSIAN AZNIV 5 LAWNDALE AVE WALTHAM, MA TEL
02154-6830
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YESE NO El
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 , 13 14
BATHTUB
CROSS CONNECTION DEVICE 1
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
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 Walter Nye LICENSE X2083 SIGNATURE
MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Nye Plumbing & Heating ADDRESS 349 Great Western Road
CITY Harwich STATE MA ZIP 02645 TEL
FAX CELL 5082463349 EMAIL
•
ROUGH PLUMBING INSPECTION NO"FFS BELOW FOR OFFICE USE ONI,V FINAL INSPECTION NOTES
1'es No
THIS APPLICATION SERVE AS THE ❑ ❑
D CD MIT
FEES$ PERMIT#
PLAN REVIEW NOTES