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HomeMy WebLinkAboutBLDP-23-005448 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,r c, CITY YARMOUTH MA DATE 3/31/23 PERMIT# BLDP-23-005448 y JOBSITE ADDRESS 33 RHINE RD OWNERS NAME CANNON JEFFREY D P OWNER ADDRESS CANNON CHRISTY M 33 RHINE RD YARMOUTH PORT,MA 02675-2464 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES❑ NO❑ 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 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 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 Douglas Langtry LICENSE 1f1305 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME AQUA SERVICES ADDRESS 1200 Route 28 1268 ROUTE 28 CITY South Yarmouth STATE MA ZIP 02664 TEL 5086193367 FAX CELL EMAIL doug-aqua@comcast.net MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i= CITY YARMOUTH MA DATE 3/31/2023 PERMIT# JOBSITE ADDRESS 33 RHINE ROAD OWNER'S NAME CANNON OWNER ADDRESS SAME TEL 508-294-3232 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL❑■ PRINT CLEARLY NEW: El RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0 FIXTURES-1 FLOOR-4 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 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL ` V sue.- D SERVICE/MOP SINK _ E TOILET U / 3 2023 URINAL MA WASHING MACHINE CONNECTION WATER HEATER ALL TYPES t WATER PIPING B ILDIN� DENARTME By- OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES CI 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 ue and accurate to t t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pe ' n rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME DOUG LANGTRY LICENSE# 11305 G U MP El JP❑ CORPORATION ❑# PARTNERSHIP El# LLC 0# 3081 COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1200 ROUTE 28 CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-619-3367 FAX 508-619-3367 CELL EMAIL DOUG-AQUA@COMCAST.NET