HomeMy WebLinkAboutBLDP-23-004460 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 2/13/23 PERMIT# BLDP-23-004460
' JOBSITE ADDRESS 111 FOREST RD OWNER'S NAME THOMAS MESPELLI TR
P OWNER ADDRESS MESPELLI IRREVOCABLE FAMILY TRUST 111 FOREST RD SOUTH YARMOUTH, TEL
MA 02664
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT:El PLANS SUBMITTED: YES❑ NO El
FIXTURFS 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
1 FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK_ _
LAVATORY
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER
WATER PIPING
OTHER 1
OTHER DESCRIPTION: Shower vale
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 El OTHER TYPE OF INDEMNITY El BOND El
OWNER'S INSURANCE'NAIVER:I am aware that the licensee does not have tie 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 tre 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 permi: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 Jeffrey Krula LICENSE#b036 SIGNATURE
MP El JP ❑ CORPORATION ❑# [ PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Bath Fitter ADDRESS 25 Turnpike St
CITY West Bridgewater STATE MA ZIP 023791004 TEL 5085212700
FAX —I CELL 5087287718 7 EMAIL