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HomeMy WebLinkAboutBLDP&G-22-005942 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'April17,2022 I PERMIT# BLDP-22-005942 JOBSITE ADDRESS 30 OLD SALT LN OWNER'S NAME WRIGHT BENJAMIN M G OWNER ADDRESS 30 OLD SALT LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL U PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT© PLANS SUBMITTED:YES❑ 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 I 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 © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 0 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 'Fernando Coelho I LICENSE 34508 SIGNATURE MP❑MGF 0 JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: I ADDRESS. 116 Wildwood Path, CITY (West Yarmouth I STATE MA ZIP 02673 TEL FAX 1 I CELL I I EMAIL Ifemando252c(o.gmail.com S310N M31A32:1 NVld #.IW2ild $:33d ❑ ❑ 111N213d 3H1 SV S3A2f3S NOLLVOIlddV SIHJ oN saA S310N N01103dSNI 1VNI3 AlN0 3Sl 2i01O3dSNI 2303 3OVd SIHI S310N N01103dSNI SVO HDflO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4117/22 PERMIT# BLDP-22-005942 JOBSITE ADDRESS 30 OLD SALT LN OWNER'S NAME WRIGHT BENJAMIN M P OWNER ADDRESS 30 OLD SALT LN YARMOUTH PORT, MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: El RENOVATION: El REPLACEMENT: El 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 El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND El 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 Fernando Coelho LICENSE #508 SIGNATURE MP El JP ❑ CORPORATION ❑# PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME I ADDRESS 16 Wildwood Path CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL fernando252c@gmail.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