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Home My WebLink AboutBLDP&G-19-005779 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY South Yarmouth MA DATE 3/29/2019 PERMIT#• lC 77-6 '�5 77( 1 JOBSITE ADDRESS 48 Grandview Dr OWNER'S NAME Elaine Polley — _I OWNER ADDRESS TEL 508-394-4677 FAX I ^I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES!-1 NO FIXTURES 1 FLOOR-0 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 SYSTEM DISHWASHER _ DRINKING FOUNTAIN _ FOOD DISPOSER _ FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) _ KITCHEN SINK _ LAVATORY ROOF DRAIN _ SHOWER STALL _ SERVICE I MOP SINK _ TOILET _ URINAL — WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING 1 OTHER f ' 1 — 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. CHECK ONE ONLY: OWNER AGENT 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 Maille LICENSE# 11355 SIGNATURE MP JP CORPORATION # PARTNERSHIP # LLC ' # 3609 COMPANY NAME HomeServe USA Energy Services NE LLC ADDRESS 5 Constitution Way CITY Woburn STATE MA ZIP 01801 TEL 781 359 2620 FAX CELL EMAIL rachel.whittick@homeserveusa.com� 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 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kre_5 /r;CITY South Yarmouth MA DATE 3/29/2019 PERMIT# l/)fi/ �/ 577(/ JOBSITE ADDRESS 48 Grandview Dr OWNER'S NAME Elaine Polley GOWNER ADDRESS Elaine Polley TEL 508-394-4677 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS-. BSM 1 2 i 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES / NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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 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. I ` ` _ ��ti PLUMBER-GASFITTER NAME Michael Maille LICENSE# 11355 SIGNATURE 1 MP i MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC i # 3609 COMPANY NAME: HomeServe USA Energy Services NE LLC ADDRESS 5 Constitution Way CITY Woburn STATE MA ZIP 01801 TEL 781-359-2620 FAX CELL EMAIL rachel.whittick@homeserveusa.com -i` /f ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1