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HomeMy WebLinkAboutBLDP-23-005534 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 11-(7r 71. CITY YARMOUTH MA DATE 4/5/23 PERMIT# BLDP-23-005534 �= -— JOBSITE ADDRESS 30 TOWN HALL AVE OWNER'S NAME FRENCH JOHN S n OWNER ADDRESS FRENCH JULIA T 30 TOWN HALL AVENUE SOUTH YARMOUTH,MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑ FIXTURES FLOORS—r BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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❑ 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❑ 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 Douglas Langtry LICENSE 1/1305 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME AQUA SERVICES ADDRESS 1200 Route 28 1268 ROUTE 28 CITY South Yarmouth STATE MA ZIP 02664 TEL 5086193367 FAX CELL EMAIL doug-aqua@comcast.net ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE El ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK YARMOUTH 4/4/2023 g61)/7"^ Cam �` =C 5 y' ,f� CITY MA DATE PERMIT # / m r,1 30 TOWN HALL AVENUE FRENCH JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS SAME TEL 508-364-8438 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 7 RESIDENTIAL It PRINT CLEARLY NEW: RENOVATION: n REPLACEMENT: ICI PLANS SUBMITTED: YES ❑ NO rill FIXTURES Z FLOOR-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 ROOF DRAIN SHOWER STALL R E C E 4 V F D SERVICE / MOP SINK TOILET _ URINAL PR 05 2023 WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES J r3U LDING DEPARTMENT WATER PIPING ey._ OTHER INSURANCE COVERAGE: I have a current IiabilitYinsurance 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 n 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. CHECK ONE ONLY: OWNER Li AGENT 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 b pliance wit all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lis s PLUMBER'S NAME DOUG LANGTRY LICENSE # 11305 / k NATURE MP ■ JP f CORPORATION t# PARTNERSHIP 7 # LLC ■ # 3081 COMPANY NAME AQUA SERVICES PLUMBING & HEATING ADDRESS 1200 ROUTE 28 CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-619-3367 FAX 508-619-3367 CELL EMAIL DOUG-AQUA©COMCAST.NET ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES