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HomeMy WebLinkAboutBLDP-23-003906 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �� = CITY YARMOUTH MA DATE 1/18/23 PERMIT# BLDP-23-003906 I_�= JOBSITE ADDRESS 65 HAZELMOOR RD OWNERS NAME Seth Ritchie P OWNER ADDRESS 65 HAZELMOOR RD SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES El NO❑ FIXTURES z FLOORS--P 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 1 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 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❑ 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 (Dennis Gagne I LICENSE 9i804 SIGNATURE MP © JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# LLC ❑# I COMPANY NAME DENNIS M GAGNE ADDRESS 131 Cherrywood Ln CITY IMarstons Mills I STATE IMA I ZIP 1026481761 I TEL I • I FAX I I CELL I 1 EMAIL Igagnedmg51@aol.com 1 _ ,__.. /SAP: Pi izeee : aZ,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ....t.'r):. CITY I Q6,AZ t�vt 4. I MA .DATE I ►al.-3 G-,_ 2 1 PERMIT# LL OWNER'S NAME 5.. 4 4\ K►TG Irri.e, I JOBSTTE ADDRESS (0� u�2 e.l mGc:2 I I F .OWNER ADDRESS I TELI (FAX I I TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL - PRINT CLEARLY NEW:❑ RENOVATION:Ca-- REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ 'FIXTURES 1 FLOOR-. 1 BSM 1 j 2 3 1 4 5 I 6 J 7 ,1 8 J 9 10 I 11 1 12 13 14 BATHTUB • CROSS CONNECTION DEVICE . • DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM •-f �,. - DEDICATED GREASE SYSTEM I I DEDICATED GRAY WATER SYSTEM 1 • DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 . ; „ DRINKING FOUNTAIN 4: FOOD DISPOSER i y FLOOR/AREA DRAIN . . __ -- INTERCEPTOR(INTERIOR) , KITCHEN SINK LAVATORY ROOF DRAIN x - _.a. SHOWER STALL L , _ SERVICE l MOP SINK r _N ,. ' - , s � �. i TOILETI MIN -L a r URINAL y WASHING MACHINE CONNECTION 1 s WATER HEATER ALL TYPES -_ , 0. WATER PIPING - ,f VI-_ ®. -�i Iir i r INSURANCE COVERAGE: • I have a current)lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1Z1.-NO ❑ 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 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. . 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. . .--70 d PEE -PLUMBER'S NAME I Nta 1\iS (' �nN/- !LICENSE#I 61gO Ct I SIN TU MP( JP CORPORATION 3)--31 IPARTNERSHIP❑# LLC❑# • COMPANY NAME ( i( Pak A—R P4 a YzA,e I ADDRESS _ A e&im P s I crnrl w, .ts, v 1 STATE IlrAA I ZIP 0)-693 I TEL '?) u-E 6-6'1Ei( FAX I I CELL I EMAIL (mod--G() ON0A - c 1 (e (oc.Ce+r✓.. I