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HomeMy WebLinkAboutBLDP&G-22-006764 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 5/23/22 PERMIT# BLDP-22-006764 JOBSITE ADDRESS 2 GARDINER LN OWNER'S NAME(FOLEY DANIEL P P OWNER ADDRESS FOLEY MAUREEN A 69 KINGS CT DERBY,CT 06418 224 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES El NO El 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 El NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY El 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 LEON CLARK LICENSE Massachusetts SIGNATURE MP ❑ JP El CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME TC TYNDALL&CLARK ADDRESS 18 ATLANTIC AVE CITY SOUTH DENNIS STATE MA ZIP 102660 TEL 5083858868 FAX CELL I EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No ( 11:4- G 1` THIS APPLICATION SERVE AS THE ❑ El ( 0 Z z L S FEES S PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vfil CITY YARMOUTH MA DATE May 23,2022 PERMIT# BLDP-22-006764 JOBSITE ADDRESS 2 GARDINER LN OWNER'S NAME FOLEY DANIEL P G OWNER ADDRESS FOLEY MAUREEN A 69 KINGS CT DERBY CT 06418 224 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO 111 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 J 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 LEON CLARK LICENSE# Massachusetts SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: TC TYNDALL&CLARK ADDRESS. 18 ATLANTIC AVE, CITY SOUTH DENNIS STATE MA ZIP 02660 TEL 5083858868 FAX CELL EMAIL S310N M3IA3H NV1d #1I1N2i3d $ :33d 1=3] 7 7 AJ / 7 �J^ ❑ ❑ 11112Ed 3E11 SV S3A13S NOliV011ddd SIHJ oN s8A S310N N01103dSNI lYNId AINO 3Sfl 210103dSNI 2JOd 3OVd SIHI S310N N01103dSNI We HJf1021