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HomeMy WebLinkAboutBLDP-23-001019 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r. CITY YARMOUTH--k: MA DATE 8/25/22 PERMIT# BLDP-23-001019 t I JOBSITE ADDRESS 75 ASTOR WAY OWNER'S NAME KENNELLY VICKI ���p OWNER ADDRESS 75 ASTOR WAY SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO❑ FIXTURFS • 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 1 _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❑ 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 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 Jeff ryan LICENSE 3/1068 SIGNATURE MP 0 JP ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADDRESS 8 russells path CITY marstons mills STATE MA ZIP 02648 TEL FAX CELL 5082803678 EMAIL osandsky@gmail.com • • i ASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK .=_u,= .,r' ! / I ��/ MA DATE T'/[(/lam 2 PERMIT* Z 3— /O/� =1- ' B• DDRESS l 4 io �f7 OWNER'S NAME irelAellereCY 242D'� Q 0 -• ' 'DRESS S�/`"1 S TEL V8 Z 7/5,'AX ,U 'E-0- - T M E , Y TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL ►:4 CLEARLY NEW:❑ RENOVATIONS REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOO FIXTURES 7 FLOOR-4 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 - f • - ROOF DRAIN SHOWER STALL , SERVICE I MOP SINK TOILET - URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING t OTHER _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY illi 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. c CHECK ONE ONLY: OWNER 0 AGENT 0 SC SIGNATURE OF OWNER OR AGENT 41 I hereby certify that all of the details and information I have submitted or entered regarding this application are a an. :ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in•.i'•- all Pertinent provision Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��� PLUMBER'S NAME VA/t LICENSE# I O09. r ' / SIGNATURE MP❑ . JP g nCORPORATION❑# PARTNERSHIP❑.# LLC❑# NAME" Zf /v P/I ADDRESS 9 12V.c �S m'%' COMPA�NYN/� �/� j�Q CITY�'I/14/ 7 7�"�' / � 5 STATEAM' ZIP 00 • `T $ TEL -- - n— �+,q y�/ FAX -� CELIK 2g0 2�J�� EMAILOS I/WS e C3O���'T CSC"