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HomeMy WebLinkAboutBLDP-22-001163 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK iSifCITY YARMOUTH MA DATE 8/31i21 PERMIT# BLDP-22-001163 JOBSITE ADDRESS 15 BURCH RD OWNERS NAME FERULLO GLORIA R TR P OWNER ADDRESS 26161 SUMMER GREENS DR BONITA SPRINGS,FL 34135 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL al PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 _ 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❑ OTHER TYPE OF INDEMNITY❑ BOND 0 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 hue 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 'David Houde I LICENSE 16673 SIGNATURE MP ❑ as ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME I ADDRESS 11016 Queen anne rd CITY Harwich STATE MA ZIP 02645 TEL I FAX I CELL EMAIL davidhoude6@gmail.com I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVE AS THE El FEES$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK { CITY ta^t `\ MA DATE u / PERMIT# .Z Z �c l l JOBSITE ADDRESS / /,L.- --' OWNER'S NAME F �10 W OWNER ADDRESS TEL FAX st`P OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�-••"" .Li `-PRINT r L m EARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:UV PLANS SUBMITTED: YES❑ NO❑ FIX! 1-ES 7 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/OILISAND 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 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 PE 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. `• CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT mil`l I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 co an with all Pertinent pr Sion o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��� PLUMBER'S NAME Oa L i C, /l�'/0 v� � LICENSE# SIGNATURE MP JP❑ CORPORATION ❑# PARTNERSHIP ❑.# LLC❑# COMPANY NAME /4/0 r-f--// ADDRESS /0/ G (.E'cr e < L/ CITY 74/0 r r (`i STATE/1_ ZIP Oc L/ r TEL FAX CELL 10EMAIL t ( J7 [. 0-11-1-et� f/ 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