HomeMy WebLinkAboutBLDP-17-003709 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Y Yarmouth MA DATE 1/12/17
CIT PERMIT# Ali /7-ev '1u('
JOBSITE ADDRESS 22 Edgewater Rd, S. Yarmouth OWNER'S NAME Steve Pezzella
OWNER ADDRESS 22 Edgewater Rd, S. Yarmouth, MA 02664 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 21
PRINT
CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:[] PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR-* SSM 1 2 3 4 5 6 7 8 9 10 I 11 12 13 14
BATHTUB 2
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY _
ROOF DRAIN _
SHOWER STALL.
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING _
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE:TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY X❑ 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.
_ CHECK ONE ONLY: OWNER [] AGENT ❑
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 acc to to the , of my kn ledge
and that all plumbing work and installations performed under the pen-nit issued for this application will be in complia� t p ' 'on a he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��ll
PLUMBER'S NAME Robert D. Fratus, Jr LICENSE# 11296 A
MP® JP❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME BC Plumbing & Heating ADDRESS PO Box 873
CITY Brewster STATE MA Zip 02631 TEL 508-896-91385
508-896-1878-clerical#
FAX 508-896-9130 CELL. 508-958-1424 — EMAIL N/A