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HomeMy WebLinkAboutBLDP-23-002881 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ci CITY YARMOUTH MA DATE 11/25/22 PERMIT# BLDP-23-002881 17, 'T JOBSITE ADDRESS 116 TEMPLETON PL OWNER'S NAME BENJAMIN ALISSA A P OWNER ADDRESS 16 TEMPLETON PL WEST YARMOUTH,MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO m 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 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 m NO El 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❑ 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 'Alex Braga I LICENSEkassachusetts I SIGNATURE MP © JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I ❑# LLC I I COMPANY NAME (Braga Brothers Inc I ADDRESS 110 breeds hill road Unit#5 `------J CITY Hyannis STATE MA ZIP 026011864 TEL 5088274260 FAX CELL 7744870199 EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YYARMOUTH I MA DATE (November 25,2024 PERMIT# BLDG-23-002882 JOBSITE ADDRESS 116 TEMPLETON PL I OWNER'S NAME IBENJAMIN ALISSA A G OWNER ADDRESS 116 TEMPLETON PL WEST YARMOUTH MA 02673 I TEL I TYPE OR OCCUPANCY TYPE PRINT COMMERCIAL ElRESIDENTIAL CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ FIXTURES FLOORS--� PLANS SUBMITTED: YES El NO El BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 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. 12 NO❑ YES IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER 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-GASFITTER NAME MP❑ MGF❑ JP ElJGF❑ LPGI ❑ CORPORATION LICENSE #SE�JSIGNATURE PARTNERSHIP ❑#I�JLLC ❑#I I COMPANY NAME: ADDRESS. CITY STATE C�ZIP C-�TEL FAX CELL EMAIL