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HomeMy WebLinkAboutBLDP-23-002348 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 10/31/22 PERMIT# BLDP-23-002348 1i JOBSITE ADDRESS 7 RANDOLPH RD OWNERS NAME DUBOIS ROBERT E P OWNER ADDRESS 7 RANDOLPH RD YARMOUTH PORT,MA 02675 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 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 1 OTHER DESCRIPTION:condensate pump 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 LIABILITY INSURANCE POLICY❑ 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 Benjamin Diamantopoulos LICENSE 15496 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# i PARTNERSHIP ❑# LLC ❑# COMPANY NAME BENJAMIN DIAMANTOPOULOS ADDRESS 25 ANTHONY RD 25 ANTHONY RD CITY W YARMOUTH STATE MA ZIP 026733776 TEL FAX CELL EMAIL bendiamantopoulos@gmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ El FEES$ PERMIT# PLAN REVIEW NOTES ILea. 0 MASSACHU ETTS UNIFORM APPLICATION FOR A ERMI TO PERFORM PLUMBING WORK CITY /1--KI.4 00 L L1 MA DATE i �1 2"-Z- PER IT# 3 - Z 3`? Sl JOBSITEAI DRESS ! i lrt WNER'S NAME g PCr IADbR SS511/k'tt TEL FAX TYPE OR OCCUPANdY TI'PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IRINT -Ct!'*RL1f- NEW;-�_._._INNOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO[� FIXTURES 7 FLOOR-4 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 • ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 6L 1 WATER PIPING OTHER C01\10. 1 nAP i - 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 E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 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 11 Massachusetts General Laws,and that my signature on this permit application waives this requirement. • T 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 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 in compli ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER' AME 11 111'Mn r0.PO J I SE# /5 C SIGNATURE MP JP CORPORATION❑# PARTNERSHIP❑-# LLC❑# COMPANY AME L7fr&IIZI r4-1-1 ADDRESS L ! T HD gi> CITY Y� 1 Q 2,� . STATE M� ZIP f r► I J T L ✓e0 FAX CELL EMAIL /l 144 J j40 o" - "PIC? ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES 4