HomeMy WebLinkAboutBLDP-18-005828 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
)6(, CITY YARMOUTH MA DATE 4/10/18 PERMIT# BLDP-18-005828
JOBSITE ADDRESS 11 ACRES AVE OWNER'S NAME NAWOICHIK STEPHEN M
P OWNER ADDRESS NAWOICHIK SHIRLEY F 54 PRISCILLA DR PEMBROKE, MA TEL
02359-3557
TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES El NO El
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 f
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN a1:,9
INTERCEPTOR(INTERIOR) I
KITCHEN SINK 1 (/
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
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 El NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 Joseph Pires LICENSE MA SIGNATURE
MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME ADDRESS 57 Williams
CITY North Easton STATE MA ZIP 02356 TEL 5087189776
FAX CELL EMAIL
at(
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE
DFDNIIT
FEES$ PERMIT#
PLAN REVIEW NOTES