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HomeMy WebLinkAboutBLDP&G-22-007252 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK yn _ CITY YARMOUTH MA DATE 6/16/22 PERMIT# BLDP-22-007252 JOBSITE ADDRESS 39 VINEBROOK RD OWNER'S NAME SWAN MARK E P OWNER ADDRESS WILLIAMS CYNTHIA E 39 VINE BROOK RD SOUTH YARMOUTH,MA 02664 177 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL ❑ PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES El NO m 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 I NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 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 John Downey LICENSE MA SIGNATURE MP El JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME I ADDRESS 37 Bray Farm Road North CITY (Yarmouth Port STATE MA ZIP 102675 I TEL 15082215257 FAX CELL 1 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ ❑ FEES S PERMIT# PLAN REVIEW NOTES ~ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .......................... °r CITY YARMOUTH MA DATE June 16,2022 PERMIT# BLDP 22 007252 JOBSITE ADDRESS 39 VINEBROOK RD OWNER'S NAME SWAN MARK E G OWNER ADDRESS WILLIAMS CYNTHIA E 39 VINE BROOK RD SOUTH YARMOUTH MA 02664 177 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL Q PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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❑ 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 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 John Downey LICENSE# MA J SIGNATURE MP❑ MGF ❑ JP 0 JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP 0# Lc ❑# COMPANY NAME: ADDRESS. 37 Bray Farm Road North, CITY Yarmouth Port STATE MA ZIP 02675 TEL 5082215257 FAX CELL I _EMAIL S31ON M3IA321 NYld #111V:13d $:33d ❑ ❑ 1I11d3d 3Hl SV S3AH3S NOI1V011ddV SIHI oN saA S31ON NO1103dSNI 1VNId A1NO 3Sf H0103dSNI 2:03 30Vd SIHI S314N NO1103dSNI SVO HOflO J