HomeMy WebLinkAboutBLDP-23-005661 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH J MA DATE 4/11/23 PERMIT# BLDP-23-005661
t�-
JOBSITE ADDRESS 3120 HEATHERWOOD OWNER'S NAME BURNS CAROL
P OWNER ADDRESS 258 JOHN DYER RD LITTLE COMPTON 02837-0000 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL D RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
FIXTURES 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 2
ROOF DRAIN
SHOWER STALL 2
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 El
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 Paul Gorgone LICENSE 20873 SIGNATURE
MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME PAUL R GORGONE ADDRESS PO BOX 1566 11 FROG TREE LANE
CITY EAST DENNIS STATE MA 7 ZIP 026411566 TEL
FAX CELL -I EMAIL paulgorgone@gmail.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE 0 0
FEES$ PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ,,(( --VIIIC b MA DATE < 4R7vifi` 2 00 5
JOBSITE ADDRESS OWNER'S NAME E (V1 p(( -i-vo
POWNER ADDRESS ! 9 0 146 44 ._- -'O TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL❑
PRINT /
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:��,1' PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7. FLOOR-* BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM I R E C E r ' q
DEDICATED GAS/OIL/SAND SYSTEM L� i
DEDICATED GREASE SYSTEM I r I APR 1 1 all _ 1
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM L -_J
rdkl l�AL� «1 • ti M E i 1 T
DISHWASHER I ;y �__ I
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN '
INTERCEPTOR(INTERIOR)
KITCHEN SINK f
LAVATORY # .
ROOF DRAIN
SHOWER STALL �-
SERVICE/MOP SINK
TOILET __ 1
URINAL
, WASHING MACHINE CONNECTION '
WATER HEATER ALL TYPES —_
WATER PIPING _
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial egiivalent which meets the requirements of MGL Ch.142. YES Er NO E
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY ❑,,. OTHER TYPE OF INDEMNITY ❑ BOND El
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
11 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
T CHECK ONE ONLY: OWNER [1] AGENT [---J
SIGNATURE OF OWNER OR AGENT
Ill I hereby certify that all of the details and information I have submitted or entered regarding this application are true ands rate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian all Perti t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the Gene-al Laws. _,---
CL--__
PLUMBERS NAME LICENSE# dd(y J?> SIGNATURE
MP El JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME OalitylQ- 4'•t
ADDRESS / j -)C S
CITY P'v (1 c 5 STATE 4/1/1,4- ZIP 0 2_cCJ 3 TEL a A- 5702 / (T/7
FAX CELL /4- EMAIL
L
0
H
U
La
z
w
oEl
z
ri)L1
o F Er)
La
w 0
O Q > j
o LU 0_
W
� Ii
�
u_
H
0
z
0
H
U
CS
z
5
0
x