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HomeMy WebLinkAboutBLDP-22-003567 GARAGE MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK U�>in-- CITY YARMOUTH MA DATE 12/28/21 PERMIT# BLDP-22-003567 1� ` JOBSITE ADDRESS 179 CENTER ST OWNER'S NAME Mike Leterra P OWNER ADDRESS 179 CENTER ST YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL C3 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 19 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 WATER PIPING OTHER 1 OTHER DESCRIPTION:bar sink 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 Troy Gilbert LICENSE 1t3573 SIGNATURE MP © JP 0 CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME COASTAL MECHANICAL ADDRESS 21 L Fruean Ave CITY IWAREHAM STATE MA ZIP 025711324 TEL FAX I I CELL EMAIL Ilisa@coastalphc.com oE E M SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 6 'FAY�w a • MA DATE 12/13/2021_ PERMIT# 2 2—3 5 b7 --- •a:- i DRESS 179 Center Street-Ga OWNER'S NAME Mike Leterra :UILD NG DEP.RT , ;I RESS same . .a... TEL: FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL D RESIDENTIAL D PRINT CLEARLY NEW: RENOVATION:0 REPLACEMENT:EI PLANS SUBMITTED: YES NOD FIXTURES 1 FLOOR—I 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 SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL r yr rf ._. -r r. W 11 , is • SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES r WATER PIPING OTHER bar sink INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El 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 BOND D 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 El 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. .4, PLUMBER'S NAME TroyGilbert TU 'LICENSE# 13573 SIGNATURE MP MPD JP CORPORATION Q# 'PARTNERSHIP[, # LLC 4350 COMPANY NAME Coastal Mechanical ADDRESS 21 L Fruean Ave CITY South Yarmouth r STATE J MA I ZIP 102664 1 TEL 1508-737-8747 1 FAX CELL 508-850-6955 I EMAIL lisa hc.com