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HomeMy WebLinkAboutBLDP-23-002758 .►a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • c/ CITY YARMOUTH MA DATE 11/17/22 PERMIT# BLDP-23-002758 I' 1. JOBSITE ADDRESS 256 WINSLOW GRAY RD OWNER'S NAME FLANDERS ANN MARIE TR P OWNER ADDRESS FLANDERS REVOCABLE TRUST 252 WINSLOW GRAY ROAD WEST YARMOUTH, TEL MA 02673 TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL m PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES El NO m FIXTURES z FLOORS--F BSM 1 2 3 4 5 6 7 8 9 10 1 t 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 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 0 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. 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 Henri emery LICENSE 32071 SIGNATURE MP 0 JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Emerys plumbing and heating ADDRESS 97 wareham rd CITY marion STATE MA ZIP 02738 TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 17,202; PERMIT# BLDP-23-002758 JOBSITE ADDRESS 256 WINSLOW GRAY RD G OWNER'S NAME FLANDERS ANN MARIE TR OWNER ADDRESS FLANDERS REVOCABLE TRUST 252 WINSLOW GRAY ROAD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE PRINT COMMERCIAL El COMMERCIAL CLEARLY NEW: 0FL00RS RENOVATION:❑ REPLACEMENT: BSM =© PLANS SUBMITTED: YES 0 NO FIXTUREBOILER _=�= 6 7 8 9 10 11 12 ® 14 BOOSTER _____= =_____ CONVERSION BURNER ________-____ COOK STOVE __-___________ DIRECT VENT HEATER _____- 1111111111111111111 DRYER ===________ ____11.111111111111 ___- IMESTIIIIIIminmFRYOLATOR _______==_�_S_- 11111111111 GENERATOR =__�___===__- ___ __- LABORATORY HEATER =_____= =_____- LABORATORYCOCKS _ ____________- OVEN 023122 __________IIIIIIIIIIII==_- POOLHEATER ====�_�__-__ _- ROOM/SPACE HEATER ___===_____=== ROOF T•OP UNITiiimminniiiiiiii_______=IIIII NM NM 1.1 11111 Ell Ell_--___- 11111 UNVENTED ROOM HEATER ___===_____===- OTHER =_____===____�- IIIIIIIIIIIIIIIII OTHER DESCRIPTION: _—______===__- I have a current Iiabili insurance policy or its substantial equivalent which meets the requireNCE ments s of MGL Ch.142. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW YES © NO El LIABILITY INSURANCE POLICY OTHER OF INDEMNITY❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not Ve 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 knowledge and that all plumbing work and installations performed under the permit issued for this a provision of the Massachusetts State Plumbing to the best of my Code and Chapter 142 of the General Laws. application will be in compliance with all Pertinent PLUMBER-GASFITTER NAME EMILEIMMIllin MP CI MGF 0 JP 0 JGF 0 LPGI 0 LICENSE# 32071 CORPORATION 0#C� SIGNATURE COMPANY NAME: Emerys plumbing and heating PARTNERSHIP 0# I-� ADDRESS. ��LLC ❑# CITY marion g7 Wareham rd, FAX STATE ZIP 02738 CELL EMAIL TEL