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Home My WebLink AboutBLDP-22-005831 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w, f CITY YARMOUTH MA DATE 4/12/22 PERMIT# BLDP-22-005831 r JOBSITE ADDRESS 3 PUMP HOUSE LN OWNERS NAME[KOWALSKI EDWARD J JR P OWNER ADDRESS PARENTEAU KATHRYN B 3 PUMP HOUSE LANE WEST YARMOUTH,MA 02664 TEL _ TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL al PRINT CLEARLY NEW:❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURFS • FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 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 1 ROOF DRAIN SHOWER STALL 1 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❑ 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 'Charles Delvecchio LICENSE 113269 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ICHARLES M DELVECCHIO I ADDRESS IPO BOX 719 CITY FORESTDALE STATE MA ZIP 026440702 TEL FAX I I CELL EMAIL (none ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES$ PERMIT# PLAN REVIEW NOTES CID - APPLICATION # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _f _ �1 CITY L. Yt-4\414v-\,Ciu- MA DATE L-} -t Z PERMIT # � " ' S 1 JOBSITE ADDRESS fUrV> �, L OWNER'S NAME, 11{0‘..019- S V I OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: [ RENOVATION: 4 REPLACEMENT:❑ PLANS SUBMITTED: YES 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/OiVSAND 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 El F . V , D SHOWER STALL SERVICE/ MOP SINK AP . 1 2022 TOILET 1 I URINAL - J WASHING MACHINE CONNECTION By `x'f ' ' ''vi NT 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 Eff 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. 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 = - . acc irate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in • pti: •: wltball Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME C i 14.- 142 Ot% ,� CC-1 A (0 LICENSE # SIGNATURE MP[ ( JP ❑ CORPORATION[Er# 2_0 PARTNERSHIP❑# LLC❑# COMPANY NAME lutOC V i vrci pAio tikcarliv 6 ' ADDRESS I9L) 60X —7(.-) CITY F-0 �- STATE 10_ ZIP C 2 L-4 . TEL ( 2, FAX CELL c, 72 EMAIL c t t 'L'` I ,"'1h��j ri Y1e<=1t i:Nc, L. 3 t'..C.v THIS APPLICATION SERVES AS THE PERMIT YES NO FEE: $ 1)