HomeMy WebLinkAboutBLDP-23-004576 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
F ra CITY YARMOUTH MA DATE 2/17/23 PERMIT# BLDP-23-004576
JOBSITE ADDRESS 55 LAKEFIELD RD OWNER'S NAME VIERA ANDREW S
a .
P OWNER ADDRESS VIERA SUZY M 55 LAKEFIELD ROAD SOUTH YARMOUTH,MA 02664 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 0 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
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 0 NO❑
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 0
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 Paul Viera LICENSE 26989 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME PAUL A VIERA ADDRESS 3 SHADY DR
CITY HARWICH STATE MA ZIP 026452930 TEL
FAX CELL EMAIL paulsplumbing20@yahoo.com
MASSACHUSETTSCP � UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGM WORK •
U/ .t�'t, i_ .a l� 1 nMA_'4ATE 2_•tto•�2, PERMIT# �✓Lbp\2'3- {,57�J
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of TCS IAB D c• '%..7.Tti PE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL�'
ay PRINT _
t;1�AKLY NeW: cNOVATION:.S1 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
FIXTURES 1 FLOOR-. 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 SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER .
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK ,
LAVATORY X
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 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCYyj OTHER TYPE OF INDEMNITY❑ BOND 0
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 0 AGENT tz
SIGNATURE OF OWNER OR AGENT a
I hereby certify that at of the details and information I have submitted or entered regarding this applicatio d accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be iii 'hi,e j nt provision of the
Massachusetts State Plumbing mute and Chapter 142 of the General taws. i
`r
PLUMBERS NAME 14 u \I 1 e LICENSE# Z(D"1 CA SIGNATURE
MP❑ JP d CORPORATION
' '�❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME AVIA laLA's'Vto�i/1C edU /DDRESS 3 5Vv� 'y -0
CITY 1 1K1.�% ;r 4ewte� (-1- C1STATEMfl ZIP (3'il.,4rj1 11 TEL 1145351(S''Z
FAX cal 1T1535t54Z. EMAIL?alI'c5"t.W(!�It1� Zd 1 ZL'LL.6.cj
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