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HomeMy WebLinkAboutBLDP-23-005106 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK w,Ie CITY fARMOUTH 1 MA DATE 3116/23 PERMIT# BLDP-23-005106 r. JOBSITE ADDRESS 6 CHECKERBERRY LN OWNERS NAME JULIE CZESNOWSKI P OWNER ADDRESS MARY JANE CZESNOWSKI 6 CHECKERBERRY LN WEST YARMOUTH 02673-0000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL E PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO m FIXTURFS I FM ORS—. 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/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 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING 1 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 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 weh as Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME manhewcoleman LICENSE13p368 I SIGNATURE MP ❑ JP m CORPORATION OH PARTNERSHIP ❑# LLC ❑# COMPANY NAME matt coleman plumbing and heating ADDRESS 15 college st CITY west yannouth STATE MA ZIP 026733792 J TEL FAX CELL 19788854343 EMAIL