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HomeMy WebLinkAboutBLDP-23-006110 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ez CITY YARMOUTH MA DATE 5/5/23 PERMIT# BLDP-23-006110 I JOBSITE ADDRESS 182 BAXTER AVE OWNER'S NAME RJ RESORTS GREEN HARBOR OWNER ADDRESS 65 E 55TH 33RD FL NEW YORK 100220000 VILLAGE RESO vyrvER LLC P — I TYPE OR OCCUPANCY TYPE COMMERCIAL m RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:ElREPLACEMENT:ElPLANS SUBMITTED: YES NO m FIXTURES z 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 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 ❑ 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 jeffery ricardo LICENSE 13256 SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME PATRIOT PLUMBING INC ADDRESS 538 Federal Furnace Rd CITY Plymouth STATE MA ZIP 02360 TEL 5088464551 FAX ( ( CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 1/�-9140 MA` DATE 5--4•' z3 PERMI` �' 3 dota/l0 JOBSITE ADDRESS /�� )_ U ,� x- OWNER'S NAME ( �- 1 k C t'6 P OWNER ADDRESS / o— 1364-5 5— 4/C- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:f- PLANS SUBMITTED: YES 0 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 GASJOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE t MOP SINK RECEIVED TOILET URINAL WASHING MACHINE CONNECTION MAY 5 2023 WATER HEATER ALL TYPES / WATER PIPING 3UILCING LEPAR'TMENT OTHER gy INSURANCE COVERAGE: ,�T/ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I, NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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. 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 ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1422 of the General Laws. PLUMBER'S NAME -o T g(Cc-Gr6 LICENSE#/ SIGNATURE MP JP 0 CORPORATIONS/6q PARTNERSHIP❑# LLC 0# COMPANY NAME j9o' PJ—J-� —c JC ADDRESS 5 3 0�( FC;C`A(,e C ,�oL CITY ?Ay,1"t( STATE ,./.44 ZIP 0023 v G TEL 7 z-/ 7?-3 FAX CELL 5 gy6 445757 EMAIL 7et244')4-'- e • cg &zo7