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HomeMy WebLinkAboutBLDP-23-002368 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK v CITY YARMOUTH MA DATE 11/1/22 PERMIT# BLDP-23-002368 r. to ' JOBSITE ADDRESS 169 WOOD RD OWNERS NAME DEVLIN DOROTHY A P OWNER ADDRESS DUMAS KEITH E 169 WOOD RD SOUTH YARMOUTH,MA 02664-4229 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© " REPLACEMENT:❑ PLANS SUBMITTED: YES NO m FIXTURFS 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 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 ken duarte LICENSE ILIA SIGNATURE MP © JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 37 collins aye CITY Centerville STATE MA ZIP 02632 TEL FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'I V� 1,7 At CITY YARMOUTH MA DATE January13,2023 PERMIT# -�, BLDG-23-003812 JOBSITE ADDRESS 169 WOOD RD OWNER'S NAME DEVLIN DOROTHY A G OWNER ADDRESS DUMAS KEITH E 169 WOOD RD SOUTH YARMOUTH MA 02664-4229 TYPE OR OCCUPANCY TYPE TEL PRINT TEL ❑ RESIDENTIAL CLEAR BUR SLY NEW: FLOORS❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO BSM 1 2 3 4 BOILER _ 5 6 7 8 9 10 11 12 13 1113 BOOSTER - CONVERSION BURNER - COOK STOVE 1 �- DIRECT VENT HEATER _ _ _ DRYER 1111 1111 FRYOLATOR ________11111 FURNACE __ __ - GENERATOR - INFRARED HEATER � LABORATORY COCKS ===_____-_ - MAKEUP AIR UNIT _ - OVEN _ ____C1111 POOL HEATER _ - ROOM/SPACE HEATER - ROOF TOP UNIT __ ___===- TEST _____ - UNIT HEATER _ - UNVENTED ROOM HEATER _ - WATER HEATER __ S___==- OTHER - OTHER DESCRIPTION: - 11111111111111111111.11111111.0.1111111111111111111111111111111111111.11.........0 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW YES El NO❑ 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 Kenneth Duarte LICENSE# MA SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPGI Cl CORPORATION❑# PARTNERSHIP ❑#C�LLC ❑#� COMPANY NAME: ADDRESS. 37 collins ave, CITY Centerville I STATE MA ZIP 026322345 TEL FAX I CELL EMAIL