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HomeMy WebLinkAboutBLDP-23-005703 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/13/23 PERMIT# BLDP-23-005703 '- JOBSITE ADDRESS 119 PAMET RD OWNER'S NAME STADFELD L SETH P OWNER ADDRESS STADFELD ELAINE B 102 STANDISH RD NEEDHAM,MA 02494 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES NO❑ FIXTURES FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 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 El 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. PLUMBERS NAME CCARL RIEDELL I LICENS48246 I SIGNATURE MP ❑ JP 0 CORPORATION ❑# PARTNERSHIP ❑# I I LLC ❑# I COMPANY NAME CARL F.RIEDELL&SON,INC. ADDRESS 1778 MAIN STREET CITY IOSTERVILLE I STATE IMA I ZIP 1026550000 I TEL 15084286365 FAX I CELL I I EMAIL Ierin@carlriedell.com _. M CA p D a r c e_ , 4'''''-''''' • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PL UMBING LUMBING WORK l= sf_f=11 CITY ;�m0 �h MA DATE I / J2s PERMIT# JOBSITE ADDRESS h Pa it f m-d OWNER'S NAME MaZZOFCITO POWNER ADDRESS il i I TEL 'LfZS - 3b AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(" PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:EJ PLANS SUBMITTED: YES❑ NO FIXTURES 7 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ,SHWASHER INIMMIEMII 1-- DRINKING FOUNTAIN =— ==_ I FOOD DISPOSER 11111.1111 i _00OOR/AREA DRAIN --_MIMI INTRCEPTOR(INTERIOR) � KITCHEN SINK I LAVATORY _==1.1111111_ ROOF DRAIN • _---___ I SHOWER STALL SERVICE/MOP SINK TOILET URINAL �S__ W SHING MACHINE CONNECTION —1 WATER HEATER ALL TYPES I 11.111.11 1 WATER PIPING INSURANCE COVERAGE:I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES, NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY A OTHER TYPE OF INDEMNITY Y 0 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 CHECK ONE ONLY: OWNER ❑ 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 complia ith all Perti :- .rovision.f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � 1 5 C c r l S. ( PLUMBER'S NAME eGl e l LICENSE# �-gy� �� � I ATURE MPI& JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Cc.rI F. Rt eat eII r Son ADDRESS 775- i"Icc.; r, 5tcee i- CITY Oster vi t1C. STATE M/i ZIP UDCo 55 TEL 5Oa- ,-1 - co 3C05 • FAX CELL EMAIL