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HomeMy WebLinkAboutbldp-19-006047 il- retat 0,49e-sT orYs MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y ti �x CITY YARMOUTH MA DATE 4-23-19 PERMIT#//40-/q-1 'd2t997 JOBSITE ADDRESS 77 SEAVIEW AVE OWNER'S NAME JIM AUGAT POWNER ADDRESS 77 SEAVIEW AVE TEL 508-776-3450 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 • DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) __ _ KITCHEN SINK 1 , m' LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ICE MAKER 1 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. 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 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 David Simmons LICENSE# 16259 SIGNATURE MP / JP CORPORATION # PARTNERSHIP # LLC # 3975 COMPANY NAME Devlin Simmons LLC ADDRESS 4 Jeannes Way CITY Forestdale STATE MA ZIP 02644 TEL 508-648-2080 FAX CELL 508-648-2080 EMAIL DevlinSimmonsLLC@gmail.com 3s \a C)\6 LID -�C'[� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rq= `= G=" CITY YARMOUTH MA DATE 4-23-19 PERMIT#� 67 '0( CIt�JOBSITE ADDRESS 77 SEAVIEW AVE OWNER'S NAME JIM AUGAT GOWNER ADDRESS 77 SEAVIEW AVE TEL 508-776-3450 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: i RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN # . 4 E f.,..�. .r ` POOL HEATER �.- ' ROOM/SPACE HEATER �� ROOF TOP UNIT `j' i ti ' �* 1E11.a r TEST 1 • k UNIT HEATER UNVENTED ROOM HEATER �.,. f ~ r a { i WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I i NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE 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 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-GASFITTER NAME David Simmons LICENSE# 16259 SIGNATURE MP MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC i # 3975 COMPANY NAME: Devlin Simmons LLC ADDRESS 4 Jeannes Way CITY Forestdale STATE MA ZIP 02644 TEL 508-648-2080 FAX CELL 508-648-2080 EMAIL DevlinSimmonsLLC@gmail.com 3c 0Ot \ze 690 -- Glee t � � � � \� To whom it may concern, /M f , release 9 6-4oNk DJULIZ Lic.# from permits# 8 -0?-5`51 (/o 'a3-aco ). I am hiring Devlin Simmons LLC, Lic.#16259 to install/finis ' ailing the avatory and toilet. /j) 2/7 Signature: Date: 33