Loading...
HomeMy WebLinkAboutBLDP&G-22-06726 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y, CITY YARMOUTH MA DATE 5/20/22 PERMIT# BLDP-22-006726 JOBSITE ADDRESS 24 SKIPPER LN OWNER'S NAME DUNMEYER PAMELA P OWNER ADDRESS BECKHAM KRISTINA 293 CARRIAGE LN BARNSTABLE,MA 02630 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ 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 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 0 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. PLUMBERS NAME Michael Hansen LICENSE MA SIGNATURE MP ❑ JP ❑ CORPORATION ❑# ` PARTNERSHIP ❑# LLC ❑# COMPANY NAME Rusty Inc ADDRESS 222 Mid Tech Dr CITY West Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ FEES S PERMIT H PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k-k% CITY YARMOUTH MA DATE May 20,2022 PERMIT# BLDP-22-006726 Ii_ JOBSITE ADDRESS 24 SKIPPER LN OWNER'S NAME DUNMEYER PAMELA G OWNER ADDRESS BECKHAM KRISTINA 293 CARRIAGE LN BARNSTABLE MA 02630 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:© PLANS SUBMITTED: YES 0 NO FIXTURES FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER , COOK STOVE , DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR , FURNACE , GENERATOR GRILLE INFRARED HEATER , LABORATORY COCKS , MAKEUP AIR UNIT OVEN POOL HEATER , ROOM/SPACE HEATER , ROOF TOP UNIT , TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 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 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El 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-GASFITTER NAME Michael Hansen LICENSE# MA SIGNATURE MP❑ MGF 0 JP 0 JGF❑ LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: Rusty Inc ADDRESS. 222 Mid Tech Dr, CITY West Yarmouth STATE MA ZIP 02673 TEL 15087751303 FAX CELL EMAIL S310N M31A321 NYld #1.J01293d $ :33d El ❑ 111A1213d 3H1 SV S3Ab3S NOI1VOIlddV SIHI oN saA S310N NOI103dSN11`dNld A1NO 3Sfl H0103dSNI 2IOd 39t/d SIHI S3ION N01103dSNI SY9 H9f102i