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HomeMy WebLinkAboutBLDP-23-002819 _ _ ; — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK +� CITY IYARMOUTH MA DATE 111/21/22 I PERMIT# BLDP-23-002819 t.. � JOBSITE ADDRESS 1481 BUCK ISLAND RD UNIT 1CA OWNER'S NAME ILAGRUTTA THOMAS P P OWNER ADDRESS (LAGRUTTA JEANETTE E 127 PURGATORY RD CAMPBELL HALL,NY 10916 (TEL I J TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES CI NO 0 FIXTURES 1 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 0 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 Ikeith farnham I ( LICENSEI#1601 SIGNATURE MP 0 JP 0 CORPORATION ❑# PARTNERSHIP 0# LLC 0# COMPANY NAME south shore heating&Cooling ADDRESS 57 whites path CITY south yarmouth STATE MA ZIP 026641234 TEL 5083986901 FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY IYARMOUTH I MA DATE (November 21,2024 PERMIT# BLDP-23-002819 JOBSITE ADDRESS 1481 BUCK ISLAND RD UNIT 1CA I OWNER'S NAME ILAGRUTTA THOMAS P G OWNER ADDRESS ILAGRUTTA JEANETTE E 127 PURGATORY RD CAMPBELL HALL NY 10916 I TEL I TYPE OR OCCUPANCY TYPE PRINT COMMERCIAL ElRESIDENTIAL ID CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES 0 NO FIXTURES FLOORS BSM 1 2 3 4 5 6 7 g BOILER 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE • FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 OF INDEMNITY❑ 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-GASFITTER NAME keith farnham MP© MGF 0 JP E] JGF 13LPGI 13 CORPORATION L❑#SE# 11601 SIGNATURE COMPANY NAME: south shore heating&Cooling PARTNERSHIP 0#�LLC 0# ADDRESS. 57 whites path, CITY south Yarmouth STATE MA ZIP 026641234 TEL 5083986901 FAX CELL EMAIL