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HomeMy WebLinkAboutBLDP-22-004673 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 2/23/22 PERMIT# BLDP-22-004673 F.'. JOBSITE ADDRESS 1308 OLD MAIN ST OWNERS NAME 308 OLD MAIN STREET LLC P OWNER ADDRESS CIO MICHAEL LUMIA 310 OLD MAIN ST SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ PRINT CLEARLY NEW:0 RENOVATION:❑ 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY 2 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 2 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❑ 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. PLUMBER'S NAME Troy Gilbert LICENSE 26383 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# _ , LLC ❑# COMPANY NAME TROY J GILBERT ADDRESS 39 STATION ST 39 STATION ST CITY WAREHAM STATE IMA ZIP 025711324 TEL FAX CELL EMAIL katherine@coastalphc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ 0 FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK EM- � Yarmouth 02/15/2022 PERMIT# 12.- 4��� CITY MA DATE 308 Old Main St S Yarmouth MA 02664 JOBSITE ADDRESS OWNER'S NAME JCW ENTERPRISES INC pOWNER ADDRESS 308 OLD MAIN ST S YARMOUTH, MA 02664 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL IT RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION: 2 REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO [' FIXTURES -1 FLOOR-' 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 SYSTEM DISHWASHER DRINKING FOUNTAIN _ _ FOOD DISPOSER FLOOR/AREA DRAIN _ INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY 2 ROOF DRAIN _ SHOWER STALL 1 SERVICE /MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 2" NO n IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: 1 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. /vd641 CHECK ONE ONLY: OWNER ,�[ AGENT ❑ SIGN RE 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. /� GYM eAL-- PLUMBER'S NAMETroy J Gilbert LICENSE # 25383 fSf1ATURE MP ❑ JP ❑/ CORPORATION ❑ # PARTNERSHIP ❑ # LLC iyi# 4530 COMPANY NAME Cuatal Mechanical ADDRESS 21 L Fruean Ave CITY South Yarmouth STATE MA ZIP 02664 TEL 508-737-8747 FAX CELL_508-850-6955 EMAIL Katherine©Coastalphc.com