HomeMy WebLinkAboutBLDP-22-006139 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YARMOUTH MA DATE 4/26/22 PERMIT# BLDP-22-006139
JOBSITE ADDRESS 696 ROUTE 6A OWNER'S NAME MEDERIOS KIMBERLY MARIE
P OWNER ADDRESS MEDERIOS JAMES RICHARD 696 ROUTE 6A YARMOUTH PORT,MA 02675 TEL
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
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 ❑
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 MICHAEL HANSEN LICENSE 1E906 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME RUSTYS 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 ❑
FEESS PERMITS
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
a � CITY YARMOUTH MA DATE April 26, 2022 PERMIT# BLDP-22-006139
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JOBSITE ADDRESS 696 ROUTE 6A OWNER'S NAME MEDERIOS KIMBERLY MARIE
G OWNER ADDRESS MEDERIOS JAMES RICHARD 696 ROUTE 6A YARMOUTH PORT MA 02675 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO EI
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
1
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
4
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM /SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
i
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 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-GASFITTER NAME MICHAEL HANSEN LICENSE# 15906 SIGNATURE
MP ❑ MGF ❑ JP ❑ JGF 0 LPGI ❑ CORPORATION ❑ # PARTNERSHIP 0 # LLC ❑ #
COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR, ]
CITY WEST YARMOUTH STATE MA ZIP 02673 TEL 5087751303 II
FAX CELL , EMAIL1
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