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HomeMy WebLinkAboutBldp-19-006657 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 5/23/19 PERMIT# BLDP-19-006657 I JOBSITE ADDRESS 53 WHITE ROCK RD OWNER'S NAME STEVENS CHARLES L P OWNER ADDRESS STEVENS DEBRA L 53 WHITE ROCK RD YARMOUTH PORT,MA 02675-2314 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL al PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:m PLANS SUBMITTED: YES El NO m FIXTURES 1 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/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 _ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ TOILET _ URINAL WASHING MACHINE CONNECTION WATER HEATER 1 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 El 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 Richard Whiteside LICENSE 16850 SIGNATURE MP co JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME RICHARD J WHITESIDE ADDRESS 29 MAPLE TER CITY SOUTH DENNIS STATE MA ZIP 026603651 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ El FEES S PERMIT# PLAN REVIEW NOTES \(, sc- 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `71CITY YARMOUTH MA DATE May 23,2019 PERMIT# BLDG-19-006658 JOBSITE ADDRESS 53 WHITE ROCK RD OWNER'S NAME STEVENS CHARLES L G OWNER ADDRESS STEVENS DEBRA L 53 WHITE ROCK RD YARMOUTH PORT MA 02675-2314 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED:YES ❑ NO El FIXTURES FLOORS—0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 OF INDEMNITY 0 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-GASFITTER NAME Richard Whiteside LICENSE# 15850 SIGNATURE MP© MGF 0 JP 0 JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RICHARD J WHITESIDE ADDRESS. 29 MAPLE TER, CITY SOUTH DENNIS STATE MA ZIP 026603651 TEL FAX CELL EMAIL wet ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE: $ PERMIT# PLAN REVIEW NOTES � t D1 c1\ ":".'' "` \ .. .;.• •:•••,;:; . 1... . -,•. . „,... . . .„., .: . • • . .... _, ,.... N' •:,.. „,.,,,„ ... ...„ ,, ,...... , •., , ....s.'' ii4J''' I* ..'1•Iii .;•••••.4 „ • ' .. • y l $ a � • L I . 4. (. , 1tr sl '' :.1 „ R • fw P