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HomeMy WebLinkAboutBLDP-22-005323 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK uj ! CITY YARMOUTH ] MA DATE 3/23/22 PERMIT# BLDP-22-005323 JOBSITE ADDRESS 210 STATION AVE OWNER'S NAME DENNIS YARMTH REGIONAL OWNER ADDRESS (STATION AVENUE SOUTH YARMOUTH,MA 02664 SCHOOL TEL P TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 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 1 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 0 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 25383 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME TROY J GILBERT ADDRESS 39 STATION ST 39 STATION ST CITY WAREHAM STATE MA 7 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 ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 2Z 5-3 z 3 _ = CITY Yarmouth 03/22/2022 MA DATE PERMIT# • 1{ � Dennis Yarmouth School JOBSITE ADDRESS 210 Station Ave OWNERS� NAMERegional OWNER ADDRESS 296 Station Ave S. Yarmouth MA 02664 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL V EDUCATIONAL RESIDENTIAL C PRINT CLEARLY NEW: P RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES NO V FIXTURES Z FLOOR—I 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 SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 - 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 ' NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY yf 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. /(�de CHECK ONE ONLY: OWNER [ ' AGENT n SI TURE 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. �� Qi . _t PLUMBER'S NAME TroyJ Gilbert LICENSE #25383 NATURE MP ❑ JP EL CORPORATION EZI# 4350 PARTNERSHIP ❑ # LLC (J # COMPANY NAME Coastal Mechanical ADDRESS 21 L Fruean Ave CITY S Yarmouth STATE MA ZIP 02664 TEL 508-737-8747 FAX cELL508-850-6955 EMAIL Katherine@Coastalphc.com