HomeMy WebLinkAboutBLDP&G-23-000099 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
u1 �, CITY YARMOUTH MA DATE 7/7/22 PERMIT# BLDP-23-000099
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JOBSITE ADDRESS 53 WEST WOODS VILLAGE OWNER'S NAME VAUGHAN DAVID W TRS
P OWNER ADDRESS VAUGHAN LINDA A 4665 WINGED FOOT CT APT 201 NAPLES,FL 34112 796 TEL ]
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL E
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO❑
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FIXTURES • FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 , 1,1_
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 III NO El
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 keith farnham LICENSE#1601 SIGNATURE
MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# Lc ❑# ]
COMPANY NAME south shore heating&cooling ADDRESS 57 whites path ]
CITY south yarmouth STATE MA ZIP 02664 TEL 5083986901
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVE AS THE ❑
FEESS PERMIT#
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1- ���'��� July BLDP-23-000099
1 = ;i,�a r CITY YARMOUTH MA DATE 07, 2022 PERMIT#
JOBSITE ADDRESS 53 WEST WOODS VILLAGE OWNER'S NAME VAUGHAN DAVID W TRS
G OWNER ADDRESS VAUGHAN LINDA A 4665 WINGED FOOT CT APT 201 NAPLES FL 34112 796 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO El
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 ❑ NO ❑
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 keith farnham ] LICENSE# 11601 SIGNATURE
MP ❑ MGF 0 JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # ]
COMPANY NAME: south shore heating & cooling ADDRESS. 57 whites path, ]
CITY south Yarmouth STATE MA ZIP 02664 TEL 5083986901 ]
FAX [ CELL EMAIL ]
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